Healthcare Provider Details

I. General information

NPI: 1659923209
Provider Name (Legal Business Name): JACKALYNN LEE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2019
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 AMITY AVE
OLD FORGE PA
18518-1019
US

IV. Provider business mailing address

118 AMITY AVE
OLD FORGE PA
18518-1019
US

V. Phone/Fax

Practice location:
  • Phone: 570-905-0669
  • Fax:
Mailing address:
  • Phone: 570-905-0669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC011549
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: