Provider Demographics
NPI:1053575936
Name:WILSON, JENNIFER KATHRYN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHRYN
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 1:720 WOOD ST
Mailing Address - Street 2:HUMBOLDT COUNTY MENTAL HEALTH
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501
Mailing Address - Country:US
Mailing Address - Phone:707-268-2900
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-268-2939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA643092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry