Provider Demographics
NPI:1306153606
Name:WILSON-CHAN, JESSICA JILL (DO)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:JILL
Last Name:WILSON-CHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:18002 RICHMOND PLACE DR APT 124
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1725
Mailing Address - Country:US
Mailing Address - Phone:702-885-7789
Mailing Address - Fax:813-212-5367
Practice Address - Street 1:3284 COVE BEND DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2752
Practice Address - Country:US
Practice Address - Phone:813-586-0618
Practice Address - Fax:813-212-5367
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11030208D00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33864OtherBCBS
FLBM642AOtherMEDICARE GROUP PTAN
FL33864OtherBCBS