Provider Demographics
NPI:1437283264
Name:WILSON, JESSICA L (RPSGT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6269
Mailing Address - Country:US
Mailing Address - Phone:817-424-0971
Mailing Address - Fax:888-866-4929
Practice Address - Street 1:251 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6269
Practice Address - Country:US
Practice Address - Phone:817-424-0971
Practice Address - Fax:888-866-4929
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5193246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic