Provider Demographics
NPI:1053907600
Name:WILSON, JEAN YVETTE
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:YVETTE
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 1:3007 OLDE TABBY DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-9222
Mailing Address - Country:US
Mailing Address - Phone:404-731-0263
Mailing Address - Fax:678-402-7422
Practice Address - Street 1:3007 OLDE TABBY DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-9222
Practice Address - Country:US
Practice Address - Phone:404-731-0263
Practice Address - Fax:678-402-7422
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator