Provider Demographics
NPI:1699225482
Name:WILSON, JESSICA A (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2621 DRYDEN RD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1661
Mailing Address - Country:US
Mailing Address - Phone:937-281-0900
Mailing Address - Fax:937-938-9751
Practice Address - Street 1:2621 DRYDEN RD STE 100
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1646
Practice Address - Country:US
Practice Address - Phone:937-281-0900
Practice Address - Fax:937-938-9751
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP561493363A00000X
OH50.004805RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant