Provider Demographics
NPI:1669596144
Name:WILSON, JANEEN L (MA, LMFT)
Entity type:Individual
Prefix:
First Name:JANEEN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 HARMONY GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379
Mailing Address - Country:US
Mailing Address - Phone:951-692-5170
Mailing Address - Fax:
Practice Address - Street 1:1604 S SANTA FE AVE STE 430
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5062
Practice Address - Country:US
Practice Address - Phone:951-692-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43646106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist