Provider Demographics
NPI:1811341522
Name:WILSON, JESSICA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:WILSON
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 1:155 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-1521
Mailing Address - Country:US
Mailing Address - Phone:845-279-6999
Mailing Address - Fax:
Practice Address - Street 1:155 MAIN ST
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-1521
Practice Address - Country:US
Practice Address - Phone:845-279-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64627207Q00000X
MN62647207Q00000X
390200000X
NY300770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program