Provider Demographics
NPI:1326047911
Name:WILSON, JENNIFER ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:955 W SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4903
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-893-8172
Practice Address - Street 1:6351 E BROADWAY BLVD STE 115
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3510
Practice Address - Country:US
Practice Address - Phone:520-467-4457
Practice Address - Fax:520-467-4460
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2656152W00000X
AZOPT-002406152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0025-02052Medicaid
NV34205Medicare ID - Type Unspecified
NV0025-02052Medicaid