Provider Demographics
NPI:1558000117
Name:WILSON, JAQUELL
Entity Type:Individual
Prefix:
First Name:JAQUELL
Middle Name:
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 1:4807 TOOLEY DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-6631
Mailing Address - Country:US
Mailing Address - Phone:434-480-6111
Mailing Address - Fax:
Practice Address - Street 1:43 RIVES RD STE 1C
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9255
Practice Address - Country:US
Practice Address - Phone:804-805-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001301085163W00000X
342000000X, 343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No163W00000XNursing Service ProvidersRegistered Nurse
No342000000XTransportation ServicesTransportation Network Company
No343800000XTransportation ServicesSecured Medical Transport (VAN)