Provider Demographics
NPI:1144099474
Name:WILEY, JENNIFER RECHELLE (RBT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RECHELLE
Last Name:WILEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RECHELLE
Other - Last Name:LEATHERBURY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:309 HORIZON DR APT 2
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5744
Practice Address - Country:US
Practice Address - Phone:580-682-9457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-23-316919106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician