Provider Demographics
NPI:1508524026
Name:WILSON, JESSICA KAY (HM61029496)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:HM61029496
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4706
Mailing Address - Country:US
Mailing Address - Phone:360-523-3115
Mailing Address - Fax:
Practice Address - Street 1:1924 VAN WORMER ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1947
Practice Address - Country:US
Practice Address - Phone:360-330-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHM61029496374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide