Provider Demographics
NPI:1477639219
Name:WILSON, JENNIFER (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:803 HIGHWAY 31 EAST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:TX
Practice Address - Zip Code:75758-0373
Practice Address - Country:US
Practice Address - Phone:903-849-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-041OtherTRICARE
TX186968702Medicaid
TX8CW412OtherBCBS
TXP00967753OtherMEDICARE RR
TX186968701Medicaid
TX75-2616977-007OtherTRICARE DOUGLAS
TX752616977002OtherTRICARE
TXP00385523OtherTC GROUP CR1017
TXP00967753OtherMEDICARE RR
TX75-2616977-041OtherTRICARE
TXP00385523OtherTC GROUP CR1017