Provider Demographics
NPI:1255008462
Name:WYSIADLOWSKI, JAKE T
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:T
Last Name:WYSIADLOWSKI
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 1:1801 W END AVE STE 1150
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2528
Mailing Address - Country:US
Mailing Address - Phone:615-321-8881
Mailing Address - Fax:615-321-8881
Practice Address - Street 1:1801 W END AVE STE 1150
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2528
Practice Address - Country:US
Practice Address - Phone:615-321-8881
Practice Address - Fax:615-321-8874
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10378152W00000X
TN3768152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist