Healthcare Provider Details

I. General information

NPI: 1033232913
Provider Name (Legal Business Name): JENNIFER JACKSON WILSON M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 PEYTON MANNING
KNOXVILLE TN
37996
US

IV. Provider business mailing address

1600 PEYTON MANNING PASS
KNOXVILLE TN
37996-0001
US

V. Phone/Fax

Practice location:
  • Phone: 865-974-5451
  • Fax: 865-974-4639
Mailing address:
  • Phone: 865-974-5451
  • Fax: 865-974-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0000001403
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: