Provider Demographics
NPI:1518712629
Name:WILSON, JODY MAY (AS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:MAY
Last Name:WILSON
Suffix:
Gender:X
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 BUNNELL ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-1520
Mailing Address - Country:US
Mailing Address - Phone:907-888-0869
Mailing Address - Fax:
Practice Address - Street 1:1825 MARIKA RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5521
Practice Address - Country:US
Practice Address - Phone:907-474-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker