Provider Demographics
NPI:1902341209
Name:WILSON, JALA (BCBA)
Entity Type:Individual
Prefix:
First Name:JALA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JALA
Other - Middle Name:
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8609 W BRYN MAWR AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3524
Mailing Address - Country:US
Mailing Address - Phone:736-447-7877
Mailing Address - Fax:
Practice Address - Street 1:8609 W BRYN MAWR AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3524
Practice Address - Country:US
Practice Address - Phone:773-644-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-20-45615103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician