Provider Demographics
NPI:1295022622
Name:WILSON, JACQUELINE A (CONTRACTOR)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:CONTRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12257 MIDDLEBROOK SQ
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3759
Mailing Address - Country:US
Mailing Address - Phone:619-922-7290
Mailing Address - Fax:
Practice Address - Street 1:12257 MIDDLEBROOK SQ
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3759
Practice Address - Country:US
Practice Address - Phone:619-922-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor