Provider Demographics
NPI:1265007546
Name:WILEY, JONATHAN M
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:WILEY
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 1:9711 DANWOOD LN NW APT 34
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9148
Mailing Address - Country:US
Mailing Address - Phone:360-535-3287
Mailing Address - Fax:
Practice Address - Street 1:1520 NE RIDDELL RD STE 110
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3005
Practice Address - Country:US
Practice Address - Phone:360-288-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61157956101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)