Healthcare Provider Details

I. General information

NPI: 1871190983
Provider Name (Legal Business Name): JERROD JONATHAN WILSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 QUARTZ DR STE 101
VILLA RICA GA
30180-3256
US

IV. Provider business mailing address

101 QUARTZ DR STE 101
VILLA RICA GA
30180-3256
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-9445
  • Fax: 770-836-8808
Mailing address:
  • Phone: 770-836-9445
  • Fax: 770-836-8808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP326207
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28262360A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: