Provider Demographics
NPI:1811440092
Name:WILSON, JACKILYN (NP)
Entity type:Individual
Prefix:
First Name:JACKILYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SUGAR CAMP CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1981
Mailing Address - Country:US
Mailing Address - Phone:937-276-8320
Mailing Address - Fax:
Practice Address - Street 1:3120 GOVERNORS PLACE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1328
Practice Address - Country:US
Practice Address - Phone:937-293-1622
Practice Address - Fax:937-245-6308
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH019508363LA2100X
OHRN328660363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH497260Medicare PIN