Provider Demographics
NPI:1912779166
Name:CAMBRIDGE-WILSON, JALEN
Entity type:Individual
Prefix:
First Name:JALEN
Middle Name:
Last Name:CAMBRIDGE-WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 REED CT
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-3122
Mailing Address - Country:US
Mailing Address - Phone:678-891-7982
Mailing Address - Fax:
Practice Address - Street 1:1138 REED CT
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3122
Practice Address - Country:US
Practice Address - Phone:678-891-7982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-07-3468106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician