Provider Demographics
NPI:1871190983
Name:WILSON, JERROD JONATHAN (FNP)
Entity type:Individual
Prefix:
First Name:JERROD
Middle Name:JONATHAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 QUARTZ DR STE 101
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3256
Mailing Address - Country:US
Mailing Address - Phone:770-836-9445
Mailing Address - Fax:770-836-8808
Practice Address - Street 1:101 QUARTZ DR STE 101
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3256
Practice Address - Country:US
Practice Address - Phone:770-836-9445
Practice Address - Fax:770-836-8808
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2025-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPRN-NP326207363LF0000X
IN28262360A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily