Provider Demographics
NPI:1457995953
Name:JESSICA J WILSON CHAN D O PA
Entity Type:Organization
Organization Name:JESSICA J WILSON CHAN D O PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:WILSON-CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-978-0020
Mailing Address - Street 1:14522 UNIVERSITY POINT PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-5425
Mailing Address - Country:US
Mailing Address - Phone:813-978-0020
Mailing Address - Fax:813-972-9024
Practice Address - Street 1:14522 UNIVERSITY POINT PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-5425
Practice Address - Country:US
Practice Address - Phone:813-978-0020
Practice Address - Fax:813-972-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty