Provider Demographics
NPI:1205837515
Name:WILEY, JENNIFER M (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:WILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:W
Other - Last Name:RULE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:101 JORDAN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8309
Practice Address - Country:US
Practice Address - Phone:518-274-0024
Practice Address - Fax:518-274-9487
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0196142Medicaid
NYI70158Medicare PIN
NYJ400350983Medicare PIN
NYF86087Medicare UPIN