=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255139028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAQUIESE WILSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2025
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5070 MATTESON DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-229-5877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5070 MATTESON DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-229-5877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 27081237A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------