MEDICARE: JENNIFER M 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	207R00000X	Internal Medicine Physician	MD25208	OR
2	208M00000X	Hospitalist Physician	MD25208	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00351753	OTHER	OR	RR MEDICARE (P-PMG

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427031699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER M WILSON MD

Provider Business Mailing Address
First Line	:	PO BOX 3158
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3158
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 N PROVIDENCE DR
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-7485
Country	:	US
Telephone Number	:	503-537-5607
Fax Number	:

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	02/14/2022

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