Provider Demographics
NPI:1992562292
Name:WILSON, JACOB CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 SALTWELL RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-7112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:WV
Practice Address - Zip Code:26074-1082
Practice Address - Country:US
Practice Address - Phone:304-336-5294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant