Provider Demographics
NPI:1750881488
Name:WILSON, JENNIFER MICHELE (LVN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:WILSON
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 FM 2114
Mailing Address - Street 2:
Mailing Address - City:AQUILLA
Mailing Address - State:TX
Mailing Address - Zip Code:76622-2412
Mailing Address - Country:US
Mailing Address - Phone:512-202-5342
Mailing Address - Fax:
Practice Address - Street 1:20606 N INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1812
Practice Address - Country:US
Practice Address - Phone:254-405-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210280164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse