Provider Demographics
NPI:1245948066
Name:WILSON, JEFFREY (FNP)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 S CASHUA DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-6315
Mailing Address - Country:US
Mailing Address - Phone:843-250-9999
Mailing Address - Fax:843-731-9077
Practice Address - Street 1:1018 S CASHUA DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-6315
Practice Address - Country:US
Practice Address - Phone:843-250-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
SC28296363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care