Individual
JACQUELINE D WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
3760 LAVISTA RD, SUITE 102, TUCKER, GA 30084-5615
(404) 248-0415
(404) 248-0422
Mailing address
1221 PARKLAND CT SE, SMYRNA, GA 30082-4732
(404) 248-0415
(404) 248-0422
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1512
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00546653D
—
GA
Enumeration date
12/28/2006
Last updated
07/08/2007
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