Provider Demographics
NPI:1881034585
Name:WILSON, JANA LYNN (OT)
Entity Type:Individual
Prefix:MS
First Name:JANA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2156 S LUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2660
Mailing Address - Country:US
Mailing Address - Phone:417-343-7591
Mailing Address - Fax:
Practice Address - Street 1:2156 S LUSTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2660
Practice Address - Country:US
Practice Address - Phone:417-343-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003287225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist