Healthcare Provider Details

I. General information

NPI: 1982535498
Provider Name (Legal Business Name): JAQUELYN MICHELLE WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BURNEY DR
FLOWOOD MS
39232-6621
US

IV. Provider business mailing address

1075 CENTRE POINTE DR
BRANDON MS
39042-9698
US

V. Phone/Fax

Practice location:
  • Phone: 601-803-7933
  • Fax:
Mailing address:
  • Phone: 601-832-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: