Provider Demographics
NPI:1235140773
Name:WILEY, JENNIFER HAWK (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:HAWK
Last Name:WILEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 813
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-0014
Mailing Address - Country:US
Mailing Address - Phone:706-654-2155
Mailing Address - Fax:706-654-2171
Practice Address - Street 1:117 BELL AVENUE
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548
Practice Address - Country:US
Practice Address - Phone:706-654-2155
Practice Address - Fax:706-654-2171
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU93511Medicare UPIN
GA35ZCHHKMedicare ID - Type Unspecified