Provider Demographics
NPI:1982823332
Name:WILSON, JEANNE A (PHD, LAC)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9025 WILSHIRE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1825
Mailing Address - Country:US
Mailing Address - Phone:310-288-2128
Mailing Address - Fax:866-295-8001
Practice Address - Street 1:9025 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1825
Practice Address - Country:US
Practice Address - Phone:310-288-2128
Practice Address - Fax:866-295-8001
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL.A.C. A8000171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAL.A.C. A8000OtherSTATE LICENSE INFORMATION