Healthcare Provider Details

I. General information

NPI: 1457995953
Provider Name (Legal Business Name): JESSICA J WILSON CHAN D O PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3284 COVE BEND DR
TAMPA FL
33613-2752
US

IV. Provider business mailing address

18002 RICHMOND PLACE DR APT 124
TAMPA FL
33647-1725
US

V. Phone/Fax

Practice location:
  • Phone: 813-586-0618
  • Fax: 813-212-5367
Mailing address:
  • Phone: 813-586-0618
  • Fax: 813-212-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSICA JILL WILSON-CHAN
Title or Position: PHYSICIAN/OWNER
Credential: DO
Phone: 813-586-0618