Provider Demographics
NPI:1396862108
Name:WYLIE, JESSE T (ATC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:T
Last Name:WYLIE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 OLD FIELD HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:816 BROAD ST
Practice Address - Street 2:SUITE 17
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4350
Practice Address - Country:US
Practice Address - Phone:203-238-1334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0001192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer