=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730058413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA WILSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2025
-----------------------------------------------------
Last Update Date | 11/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1570 MCDANIEL DR
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19380-6672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-444-2151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 N OVERHILL RD
-----------------------------------------------------
City | MEDIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19063-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-477-6682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | SP034369
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------