Provider Demographics
NPI:1720732621
Name:WILSON, JANELLE
Entity Type:Individual
Prefix:
First Name:JANELLE
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 1:1075 EASTON AVE
Mailing Address - Street 2:TOWER-3 SUITE-4
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873
Mailing Address - Country:US
Mailing Address - Phone:732-366-9616
Mailing Address - Fax:
Practice Address - Street 1:1075 EASTON AVE
Practice Address - Street 2:TOWER 3 SUITE-4
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-366-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18-462101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor