Provider Demographics
NPI:1225687791
Name:WILSON, JACQUELINE LATIA (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:LATIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2496
Mailing Address - Country:US
Mailing Address - Phone:502-794-3894
Mailing Address - Fax:502-794-2873
Practice Address - Street 1:225 N CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2496
Practice Address - Country:US
Practice Address - Phone:502-794-3894
Practice Address - Fax:502-794-2873
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013705363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily