Healthcare Provider Details

I. General information

NPI: 1912606476
Provider Name (Legal Business Name): JACQUELYN WILES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 W PALISADE AVE # 1083
ENGLEWOOD NJ
07631-2720
US

IV. Provider business mailing address

4 W PALISADE AVE # 1083
ENGLEWOOD NJ
07631-2720
US

V. Phone/Fax

Practice location:
  • Phone: 908-671-1479
  • Fax:
Mailing address:
  • Phone: 908-671-1479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00672500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: