Provider Demographics
NPI:1407303589
Name:WILSON, JENNIFER (RN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6527
Mailing Address - Country:US
Mailing Address - Phone:440-357-2700
Mailing Address - Fax:
Practice Address - Street 1:7060 WAYSIDE DR
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6527
Practice Address - Country:US
Practice Address - Phone:440-357-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN306659163W00000X
OHAPRN.CNP.020470363L00000X
OHF0117825363LF0000X
OH020470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner