Provider Demographics
NPI:1699270520
Name:WILSON, JESSICA GAIL (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GAIL
Last Name:WILSON
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 1:190 GREENBRIER BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7237
Mailing Address - Country:US
Mailing Address - Phone:985-898-7999
Mailing Address - Fax:
Practice Address - Street 1:190 GREENBRIER BLVD STE 103
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7237
Practice Address - Country:US
Practice Address - Phone:985-898-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH20771207N00000X
390200000X
LA332549207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program