Healthcare Provider Details

I. General information

NPI: 1922865997
Provider Name (Legal Business Name): JESSE H WILSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WASHINGTON ST
BOSTON MA
02118-1951
US

IV. Provider business mailing address

10 GOVE ST
BOSTON MA
02128-1920
US

V. Phone/Fax

Practice location:
  • Phone: 617-425-2000
  • Fax:
Mailing address:
  • Phone: 617-569-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2372406
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: