Provider Demographics
NPI:1689455503
Name:WILSON, JADIE (NP)
Entity Type:Individual
Prefix:
First Name:JADIE
Middle Name:
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 1:468 REDBUD RD
Mailing Address - Street 2:
Mailing Address - City:TITUS
Mailing Address - State:AL
Mailing Address - Zip Code:36080-4735
Mailing Address - Country:US
Mailing Address - Phone:334-782-4594
Mailing Address - Fax:
Practice Address - Street 1:400 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3512
Practice Address - Country:US
Practice Address - Phone:334-277-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF08230997363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily