Provider Demographics
NPI:1922896661
Name:WILSON, OLIVIA GRACE (PTA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LELIA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4864
Mailing Address - Country:US
Mailing Address - Phone:601-397-6390
Mailing Address - Fax:601-510-2381
Practice Address - Street 1:1650 LELIA DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4864
Practice Address - Country:US
Practice Address - Phone:601-397-6390
Practice Address - Fax:601-510-2381
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7931225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant