Healthcare Provider Details

I. General information

NPI: 1659217206
Provider Name (Legal Business Name): JESSICA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 OLD LATTA HWY
DILLON SC
29536-7614
US

IV. Provider business mailing address

2017 COREYS CT
DILLON SC
29536-8064
US

V. Phone/Fax

Practice location:
  • Phone: 843-339-0883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number226765
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: