Healthcare Provider Details

I. General information

NPI: 1760004295
Provider Name (Legal Business Name): JESSICA SANTRICE WILSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 HAWTHORNE LN
ATHENS GA
30606-2152
US

IV. Provider business mailing address

PO BOX 603725
CHARLOTTE NC
28260-3725
US

V. Phone/Fax

Practice location:
  • Phone: 706-613-8500
  • Fax: 706-613-8844
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number114686
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: