Provider Demographics
NPI:1568403640
Name:WILSON, JACQUELINE S (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 E MAIN ST
Mailing Address - Street 2:SUITE 309
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6241
Mailing Address - Country:US
Mailing Address - Phone:406-586-7515
Mailing Address - Fax:406-522-0481
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:SUITE 309
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6241
Practice Address - Country:US
Practice Address - Phone:406-586-7515
Practice Address - Fax:406-522-0481
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT83152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0152425Medicaid
MT93296OtherBCBS
MT027161Medicare UPIN