Provider Demographics
NPI:1194475897
Name:WILSON, JENNA LEIGH
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 W WEBER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1923
Mailing Address - Country:US
Mailing Address - Phone:770-316-9081
Mailing Address - Fax:
Practice Address - Street 1:7688 ROWLES DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4593
Practice Address - Country:US
Practice Address - Phone:770-316-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0474656Medicaid