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General NPI Number Information
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NPI Number | 1730512179
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Entity Type | Individual
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Provider Name | MS. WAKETA JALON WILSON
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Gender | Female
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Dates
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Enumeration Date | 08/20/2013
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Last Update Date | 08/20/2013
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Provider Practice Location Address
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Address Line | 2921 NW 156TH ST
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City | EDMOND
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State | OK
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Zip | 73013-2101
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Country | US
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Telephone | 405-513-7794
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Fax | 405-513-7796
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Provider Business Mailing Address
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Address Line | 18520 RASTRO DR
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City | EDMOND
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State | OK
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Zip | 73012-9799
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Country | US
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Telephone | 405-706-7478
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Fax | 405-513-7794
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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