Healthcare Provider Details

I. General information

NPI: 1760793707
Provider Name (Legal Business Name): JESSICA L WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 E 93RD ST STE 440
CHICAGO IL
60617-3951
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 773-768-6400
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036136327
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: