Provider Demographics
NPI:1952597585
Name:WILSON, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:BOTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0690
Mailing Address - Country:US
Mailing Address - Phone:606-464-0151
Mailing Address - Fax:606-464-0152
Practice Address - Street 1:1025 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:BEATTYVILLE
Practice Address - State:KY
Practice Address - Zip Code:41311
Practice Address - Country:US
Practice Address - Phone:606-464-2401
Practice Address - Fax:606-464-3290
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100021290Medicaid