Provider Demographics
NPI:1225466634
Name:WILSON, JAMIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJAX - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:TOWER 1, 8TH FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-244-9052
Practice Address - Fax:904-244-9437
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009895800Medicaid
GA003140746AMedicaid
FL009895800Medicaid
FLHP239ZMedicare PIN
FLP01415626Medicare PIN