Provider Demographics
NPI:1730512179
Name:WILSON, WAKETA JALON
Entity type:Individual
Prefix:MS
First Name:WAKETA
Middle Name:JALON
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 1:18520 RASTRO DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9799
Mailing Address - Country:US
Mailing Address - Phone:405-706-7478
Mailing Address - Fax:405-513-7794
Practice Address - Street 1:2921 NW 156TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2101
Practice Address - Country:US
Practice Address - Phone:405-513-7794
Practice Address - Fax:405-513-7796
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor