MEDICARE: JESSICA TAYLOR WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	57111	TN

General Provider Information

NPI Number	:	1225415474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA TAYLOR WILSON MD

Provider Business Mailing Address
First Line	:	50 N DUNLAP ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38103-2800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8110 WALNUT RUN RD
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-6362
Country	:	US
Telephone Number	:	901-757-3535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2015
Last Update Date	:	06/26/2019

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