Provider Demographics
NPI:1699725663
Name:WILSON, JENNIFER BRYANT (PAC)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:BRYANT
Last Name:WILSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-7502
Practice Address - Fax:608-263-7652
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2902-23363AS0400X
WI2902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6825422Medicaid
SD100490Medicare ID - Type Unspecified
SD6825422Medicaid