Provider Demographics
NPI:1013554492
Name:WYLIE, JEREMIAH TYLER
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:TYLER
Last Name:WYLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6662 OAKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2156
Mailing Address - Country:US
Mailing Address - Phone:619-701-1610
Mailing Address - Fax:
Practice Address - Street 1:5075 SHOREHAM PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5927
Practice Address - Country:US
Practice Address - Phone:619-701-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician