Basic Information
| Provider Information | |||||||||
| NPI: | 1215461900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 S 114TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532271031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144494444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2222 S 114TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532271031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144494444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2017 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 269-140 | 01 | WI | WI STATE LICENCE - BEHAVIOR ANALYST | OTHER |