Basic Information
| Provider Information | |||||||||
| NPI: | 1689063646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | EDITH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17412 VENTURA BLVD | ||||||||
| Address2: | #820 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913163827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182674058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8330 LANKERSHIM BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916051615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189947454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190095AN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.