Provider Demographics
NPI:1205094406
Name:WILSON, JENNY LUPOVICI (MD)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:LUPOVICI
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SW GAINES ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2901
Mailing Address - Country:US
Mailing Address - Phone:503-804-6824
Mailing Address - Fax:
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2901
Practice Address - Country:US
Practice Address - Phone:503-494-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1622922084N0402X
PAMD4419442084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology