Provider Demographics
NPI:1659923209
Name:WILSON, JACKALYNN
Entity Type:Individual
Prefix:
First Name:JACKALYNN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 AMITY AVE
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1019
Mailing Address - Country:US
Mailing Address - Phone:570-905-0669
Mailing Address - Fax:
Practice Address - Street 1:1169 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4003
Practice Address - Country:US
Practice Address - Phone:570-904-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011549101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional