Provider Demographics
NPI:1700469061
Name:WILSON, JADEN ELLE
Entity type:Individual
Prefix:
First Name:JADEN
Middle Name:ELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50651-1506
Mailing Address - Country:US
Mailing Address - Phone:563-513-9660
Mailing Address - Fax:
Practice Address - Street 1:1600 1ST ST E
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-3155
Practice Address - Country:US
Practice Address - Phone:319-332-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA108421235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist