MEDICARE: DR. JEANNE A WILSON PHD., LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	L.A.C. A8000	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L.A.C. A8000	OTHER	CA	STATE LICENSE INFORMATION

General Provider Information

NPI Number	:	1982823332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNE A WILSON PHD., LAC

Provider Business Mailing Address
First Line	:	9025 WILSHIRE BLVD STE 200
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1825
Country	:	US
Telephone Number	:	310-288-2128
Fax Number	:	866-295-8001

Provider Business Practice Location Address
First Line	:	9025 WILSHIRE BLVD STE 200
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1825
Country	:	US
Telephone Number	:	310-288-2128
Fax Number	:	866-295-8001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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