Provider Demographics
NPI:1295359768
Name:WYLIE, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:WYLIE
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 1:2848 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1753
Mailing Address - Country:US
Mailing Address - Phone:619-346-8689
Mailing Address - Fax:
Practice Address - Street 1:2848 ASH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1753
Practice Address - Country:US
Practice Address - Phone:619-346-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst