Provider Demographics
NPI:1457578411
Name:WILSON, JAMIE LINN (RN)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LINN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:LINN
Other - Last Name:RIDENBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15244 COUNTY ROAD 3
Mailing Address - Street 2:
Mailing Address - City:FRAZEYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43822-9622
Mailing Address - Country:US
Mailing Address - Phone:740-973-2892
Mailing Address - Fax:
Practice Address - Street 1:15244 COUNTY ROAD 3
Practice Address - Street 2:
Practice Address - City:FRAZEYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43822-9622
Practice Address - Country:US
Practice Address - Phone:740-763-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400472160405374U00000X
OHRN.334480163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2604695Medicaid