Healthcare Provider Details

I. General information

NPI: 1538414495
Provider Name (Legal Business Name): JACI F WILSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 REDMOND RD NW
ROME GA
30165-1415
US

IV. Provider business mailing address

501 REDMOND RD NW
ROME GA
30165-1415
US

V. Phone/Fax

Practice location:
  • Phone: 706-802-3155
  • Fax: 706-368-8453
Mailing address:
  • Phone: 706-802-3155
  • Fax: 706-368-8453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN140128
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: