1417293523 NPI number — DR. ELLEN JETT WILSON RPH, PHD

Table of content: DR. ELLEN JETT WILSON RPH, PHD (NPI 1417293523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417293523 NPI number — DR. ELLEN JETT WILSON RPH, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
ELLEN
Provider Middle Name:
JETT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RPH, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417293523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 PARKSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMPSONVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29681-5241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-230-8819
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 FAIRVIEW RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SIMPSONVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29680-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-962-0251
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  7876 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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