Provider Demographics
NPI:1629596309
Name:WILKE, JARED (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:
Last Name:WILKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11440 W BERNARDO CT STE 272
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1643
Mailing Address - Country:US
Mailing Address - Phone:858-592-0995
Mailing Address - Fax:
Practice Address - Street 1:11440 W BERNARDO CT STE 272
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1643
Practice Address - Country:US
Practice Address - Phone:858-592-0995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27608103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical