=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205226925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESALYN DOVE WILSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2015
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 PROFESSIONAL PARK DR
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72830-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-705-8181
-----------------------------------------------------
Fax | 479-705-0041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 PROFESSIONAL PARK DR
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72830-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-746-1877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | P-T1518
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------