Provider Demographics
NPI:1932130200
Name:WILSON, JENNIFER L (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7644
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:200 SOUTHHAMPTON DRIVE
Practice Address - Street 2:STE 104
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203
Practice Address - Country:US
Practice Address - Phone:573-499-9009
Practice Address - Fax:573-499-4400
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112907174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207326300Medicaid
MO934924716Medicare PIN