Provider Demographics
NPI:1306229653
Name:WILEY, JENNIFER JEAN (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEAN
Last Name:WILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:159 SUNSET DR
Practice Address - Street 2:STE 102
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30597-9998
Practice Address - Country:US
Practice Address - Phone:706-482-2268
Practice Address - Fax:706-482-2294
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009249225100000X
IN05009268A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist