Provider Demographics
NPI:1891951703
Name:WILSON, JESSICA A (LDO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 THE MASTERS CV
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-6004
Mailing Address - Country:US
Mailing Address - Phone:478-746-3911
Mailing Address - Fax:478-746-9865
Practice Address - Street 1:1376 GRAY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1952
Practice Address - Country:US
Practice Address - Phone:478-743-6006
Practice Address - Fax:478-743-6008
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002136156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581400133OtherCORP TIN