Provider Demographics
NPI:1336431378
Name:WILSON, JACQUELYN L (R, MR)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:R, MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E LEE AVE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3874
Mailing Address - Country:US
Mailing Address - Phone:501-221-2504
Mailing Address - Fax:
Practice Address - Street 1:11300 FINANCIAL CENTRE PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3746
Practice Address - Country:US
Practice Address - Phone:501-221-2502
Practice Address - Fax:501-221-2504
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRTL62522471M1202X
AR3800892471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging