Provider Demographics
NPI:1265475347
Name:WILCOX, JACK EARL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:EARL
Last Name:WILCOX
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6328
Mailing Address - Country:US
Mailing Address - Phone:910-353-0581
Mailing Address - Fax:910-353-1536
Practice Address - Street 1:120 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6328
Practice Address - Country:US
Practice Address - Phone:910-353-0581
Practice Address - Fax:910-353-1536
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005586363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006283Medicaid