Provider Demographics
NPI:1700866266
Name:WILSON, JEAN ELLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-1753
Mailing Address - Country:US
Mailing Address - Phone:330-269-1934
Mailing Address - Fax:330-534-7654
Practice Address - Street 1:880 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:HUBBARD
Practice Address - State:OH
Practice Address - Zip Code:44425-1753
Practice Address - Country:US
Practice Address - Phone:330-269-1934
Practice Address - Fax:330-534-7654
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS 012551207Q00000X
OH34011096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI43995Medicare UPIN
PAI43995Medicare UPIN