Healthcare Provider Details

I. General information

NPI: 1700866266
Provider Name (Legal Business Name): JEAN ELLEN WILSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 W LIBERTY ST
HUBBARD OH
44425-1753
US

IV. Provider business mailing address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

V. Phone/Fax

Practice location:
  • Phone: 330-269-1934
  • Fax: 330-568-4267
Mailing address:
  • Phone: 814-333-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS 012551
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34011096
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: