MEDICARE: JAQUELL WILSON

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	163W00000X	Registered Nurse	0001301085	VA
2	163WH0200X	Home Health Registered Nurse	0001301085	VA
3	342000000X	Transportation Network Company
4	343800000X	Secured Medical Transport (VAN)
5	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1558000117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAQUELL WILSON

Provider Business Mailing Address
First Line	:	4807 TOOLEY DR
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-6631
Country	:	US
Telephone Number	:	434-480-6111
Fax Number	:

Provider Business Practice Location Address
First Line	:	8014 MIDLOTHIAN TPKE STE 318
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-5291
Country	:	US
Telephone Number	:	804-866-7050
Fax Number	:

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

Provider Enumeration Date	:	06/01/2022
Last Update Date	:	05/12/2025

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