Provider Demographics
NPI:1598925778
Name:WILSON, JEANNE B (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:B
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:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-0745
Mailing Address - Country:US
Mailing Address - Phone:708-795-0100
Mailing Address - Fax:708-795-0101
Practice Address - Street 1:205 E BUTTERFIELD RD # 297
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:708-795-0100
Practice Address - Fax:708-795-0101
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120843208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120843Medicaid