Provider Demographics
NPI:1851069660
Name:WILSON, JENNIFER MAC (DNP)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MAC
Last Name:WILSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:V
Other - Last Name:MAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:1802 YAKIMA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5305
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-627-6576
Practice Address - Street 1:1802 YAKIMA AVE STE 302
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5305
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-627-6576
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61218004363LF0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2202600Medicaid