Provider Demographics
NPI:1558701243
Name:WILSON, JESSICA ANN ORTEGA (DPM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN ORTEGA
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2946
Mailing Address - Country:US
Mailing Address - Phone:321-723-3500
Mailing Address - Fax:321-723-1945
Practice Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2946
Practice Address - Country:US
Practice Address - Phone:321-723-3500
Practice Address - Fax:321-723-1945
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3766213ES0103X, 213E00000X
PASC006487213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery