Healthcare Provider Details

I. General information

NPI: 1912779166
Provider Name (Legal Business Name): JALEN CAMBRIDGE-WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2849 HENDERSON MILL RD
ATLANTA GA
30341-5772
US

IV. Provider business mailing address

1138 REED CT
MONROE GA
30655-3122
US

V. Phone/Fax

Practice location:
  • Phone: 404-905-7720
  • Fax:
Mailing address:
  • Phone: 678-891-7982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-07-3468
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: