Provider Demographics
NPI:1205241791
Name:WILSON, JENNIFER E (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 NW 192ND TER
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9123
Mailing Address - Country:US
Mailing Address - Phone:620-200-3398
Mailing Address - Fax:
Practice Address - Street 1:9800 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6303
Practice Address - Country:US
Practice Address - Phone:405-419-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS114757041163W00000X
OK0096394163W00000X
OK96394367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse