Provider Demographics
NPI:1336746155
Name:WILSON, JADINE SANDRA (MED, BCBA, LBA)
Entity type:Individual
Prefix:MS
First Name:JADINE
Middle Name:SANDRA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 ATLANTIC AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-1861
Mailing Address - Country:US
Mailing Address - Phone:401-263-7829
Mailing Address - Fax:
Practice Address - Street 1:610 MANTON AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-5633
Practice Address - Country:US
Practice Address - Phone:401-263-7829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILBA00229103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-44001OtherBACB
RILBA00229OtherDEPARTMENT OF HEALTH