Provider Demographics
NPI:1467068411
Name:WILSON, JESSICA LAUREN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 BRADY AVE
Mailing Address - Street 2:
Mailing Address - City:ARBUTUS
Mailing Address - State:MD
Mailing Address - Zip Code:21227-4109
Mailing Address - Country:US
Mailing Address - Phone:302-363-5363
Mailing Address - Fax:
Practice Address - Street 1:1925 BRADY AVE
Practice Address - Street 2:
Practice Address - City:ARBUTUS
Practice Address - State:MD
Practice Address - Zip Code:21227-4109
Practice Address - Country:US
Practice Address - Phone:302-363-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNOT APPLICABLE