Provider Demographics
NPI:1114817137
Name:WILSON, JACLYN MARY (MA BCBA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARY
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4825 E DIXON ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-6456
Mailing Address - Country:US
Mailing Address - Phone:928-266-3784
Mailing Address - Fax:
Practice Address - Street 1:6335 E MAIN ST STE E4
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8966
Practice Address - Country:US
Practice Address - Phone:480-351-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst