Provider Demographics
NPI:1629622162
Name:WILSON, JESSICA PATREECE (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:PATREECE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 BRITTNEY LANE
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542
Mailing Address - Country:US
Mailing Address - Phone:252-265-2842
Mailing Address - Fax:252-640-0140
Practice Address - Street 1:7303 BRITTNEY LANE
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542
Practice Address - Country:US
Practice Address - Phone:252-265-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCWILS-K763D2207R00000X, 207RG0300X, 208D00000X, 363LA2100X, 363LA2200X, 363LG0600X, 363LC1500X, 363LP2300X, 207QA0505X, 207QG0300X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No171400000XOther Service ProvidersHealth & Wellness Coach