Healthcare Provider Details

I. General information

NPI: 1194822049
Provider Name (Legal Business Name): JACQUELINE S. WILSON, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E MAIN ST SUITE 309
BOZEMAN MT
59715-6241
US

IV. Provider business mailing address

321 E MAIN ST SUITE 309
BOZEMAN MT
59715-6241
US

V. Phone/Fax

Practice location:
  • Phone: 406-586-7515
  • Fax: 406-522-0481
Mailing address:
  • Phone: 406-586-7515
  • Fax: 406-522-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number8315
License Number StateMT

VIII. Authorized Official

Name: JACQUELINE S. WILSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 406-586-7515