Provider Demographics
NPI:1902643307
Name:WILSON, JENNA R
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:R
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 1:214 CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-7757
Mailing Address - Country:US
Mailing Address - Phone:812-664-8286
Mailing Address - Fax:
Practice Address - Street 1:700 ROSE STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:812-664-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program