Provider Information for 1790164622
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JANON WILSON LPC
Sex: Female
NPI: 1790164622
Last Updated: 2021-06-17
Certification Date: 2021-06-17
Certification Date: 2021-06-17
Details
Name | Value | ||||||||||||||
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NPI | 1790164622 | ||||||||||||||
Enumeration Date | 2015-05-26 | ||||||||||||||
NPI Type | NPI-1 Individual | ||||||||||||||
Sole Proprietor | YES | ||||||||||||||
Status | Active | ||||||||||||||
Mailing Address | 10 BANTA PL STE 107 HACKENSACK, NJ 07601-5605 United States Phone: 973-259-8557 | Fax:973-532-6961 | ||||||||||||||
Primary Practice Address | 10 BANTA PL STE 107 HACKENSACK, NJ 07601-5605 United States Phone: 973-259-8557 | Fax:973-532-6961 | ||||||||||||||
Secondary Practice Address(es) | 10 BANTA PL STE 107 | ||||||||||||||
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