MEDICARE: JENNIFER MICHELE WILSON LVN

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	164X00000X	Licensed Vocational Nurse	210280	TX

General Provider Information

NPI Number	:	1750881488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MICHELE WILSON LVN

Provider Business Mailing Address
First Line	:	163 FM 2114
Second Line	:
City	:	AQUILLA
State	:	TX
Zip	:	76622-2412
Country	:	US
Telephone Number	:	512-202-5342
Fax Number	:

Provider Business Practice Location Address
First Line	:	20606 N INTERSTATE 35
Second Line	:
City	:	WEST
State	:	TX
Zip	:	76691-1812
Country	:	US
Telephone Number	:	254-405-3313
Fax Number	:

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

Provider Enumeration Date	:	02/19/2018
Last Update Date	:	02/19/2018

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