Provider Demographics
NPI:1649275777
Name:WILCOX, JEANNETTE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:LOUISE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FAIRVIEW CLINIC- MAPLE GROVE
Mailing Address - Street 2:14500 99TH AVE N
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4545
Mailing Address - Country:US
Mailing Address - Phone:763-898-1000
Mailing Address - Fax:
Practice Address - Street 1:14500 99TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4730
Practice Address - Country:US
Practice Address - Phone:763-898-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC153922085R0001X
MN620342085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153924Medicaid
SCE80110Medicare UPIN
SC153924Medicaid
SCE801107951Medicare PIN