Provider Demographics
NPI:1528251840
Name:WILK, JACQUELINE CAROL (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:CAROL
Last Name:WILK
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 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-664-5151
Mailing Address - Fax:541-664-5155
Practice Address - Street 1:2825 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD290232080P0203X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD29023OtherMEDICAL LICENSE