Healthcare Provider Details

I. General information

NPI: 1043120959
Provider Name (Legal Business Name): JEANETTE A WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5408 AMES AVENUE
OMAHA NE
68104
US

IV. Provider business mailing address

9526 MAPLE ST
OMAHA NE
68134-5367
US

V. Phone/Fax

Practice location:
  • Phone: 402-555-0123
  • Fax:
Mailing address:
  • Phone: 402-305-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: