Provider Demographics
NPI:1457678377
Name:WILSON, JACQUELINE DEANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:DEANNA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15215-3227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2536
Practice Address - Country:US
Practice Address - Phone:412-647-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-02
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461194207R00000X, 208000000X, 2080A0000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine