Provider Demographics
NPI:1770112013
Name:WILSON, JENNIFER ROCKELL (BS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ROCKELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:ROCKELL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30210 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1540
Mailing Address - Country:US
Mailing Address - Phone:734-334-3873
Mailing Address - Fax:
Practice Address - Street 1:450 S VENOY RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-7805
Practice Address - Country:US
Practice Address - Phone:734-722-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator