Provider Demographics
NPI:1477588432
Name:WILSON, JENNIFER M (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
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:PO BOX 21418
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89515-1418
Mailing Address - Country:US
Mailing Address - Phone:775-746-3202
Mailing Address - Fax:775-770-3588
Practice Address - Street 1:235 W 6TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4548
Practice Address - Country:US
Practice Address - Phone:775-770-3188
Practice Address - Fax:775-770-3588
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10019207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016938Medicaid
NV002016938Medicaid
NV35731Medicare PIN