Provider Demographics
NPI:1780181016
Name:WILSON, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 21ST AVE, S
Mailing Address - Street 2:703 OXFORD HOUSE
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-4700
Mailing Address - Country:US
Mailing Address - Phone:615-936-0087
Mailing Address - Fax:
Practice Address - Street 1:1313 21ST AVENUE, SOUTH
Practice Address - Street 2:703 OXFORD HOUSE
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-4700
Practice Address - Country:US
Practice Address - Phone:615-936-0087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN60281207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program