Individual
JACQUI R WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPTA
Contact information
Practice address
1912 MEMORIAL AVE, LYNCHBURG, VA 24501-1708
(434) 845-8765
(434) 845-8467
Mailing address
1912 MEMORIAL AVE, LYNCHBURG, VA 24501-1708
(434) 845-8765
(434) 845-8467
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2306001329
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004978757
—
VA
01
—
192595
ANTHEM
VA
01
—
496612
MEDICARE PART A
VA
Enumeration date
10/28/2008
Last updated
10/28/2008
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