Provider Demographics
NPI:1700063559
Name:WILSON, JENNIFER A (CST)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8736
Mailing Address - Country:US
Mailing Address - Phone:208-377-0777
Mailing Address - Fax:208-377-1070
Practice Address - Street 1:6500 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8736
Practice Address - Country:US
Practice Address - Phone:208-377-0777
Practice Address - Fax:208-377-1070
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID89338246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist