Provider Demographics
NPI:1447341086
Name:WILSON, JACQUELYN L (CRNA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 KING AVE
Mailing Address - Street 2:
Mailing Address - City:FOLCROFT
Mailing Address - State:PA
Mailing Address - Zip Code:19032-1022
Mailing Address - Country:US
Mailing Address - Phone:610-891-0171
Mailing Address - Fax:
Practice Address - Street 1:58 KING AVE
Practice Address - Street 2:
Practice Address - City:FOLCROFT
Practice Address - State:PA
Practice Address - Zip Code:19032-1022
Practice Address - Country:US
Practice Address - Phone:610-891-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0012532367500000X
PARN234466L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered