Provider Demographics
NPI:1083462030
Name:WILSON, JORDYN L'NAE
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:L'NAE
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 1:714 W RIVIERA LN
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-3762
Mailing Address - Country:US
Mailing Address - Phone:559-209-0609
Mailing Address - Fax:
Practice Address - Street 1:2261 VILLA AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-4377
Practice Address - Country:US
Practice Address - Phone:559-575-8172
Practice Address - Fax:559-575-8176
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician