Provider Demographics
NPI:1740568450
Name:WILSON, JEAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-5068
Mailing Address - Country:US
Mailing Address - Phone:336-740-0897
Mailing Address - Fax:888-979-8335
Practice Address - Street 1:319 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-5068
Practice Address - Country:US
Practice Address - Phone:336-740-0897
Practice Address - Fax:888-979-8335
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR127999163W00000X, 363L00000X
NC5005315363LF0000X
NJ26NJ00418200363L00000X
NYF337917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005409Medicaid