Provider Demographics
NPI:1740738301
Name:WISE, JILLIAN (PHD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 3RD AVE N
Mailing Address - Street 2:#203
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3322
Mailing Address - Country:US
Mailing Address - Phone:574-612-5293
Mailing Address - Fax:
Practice Address - Street 1:880 6TH ST S
Practice Address - Street 2:SUITE 420
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4827
Practice Address - Country:US
Practice Address - Phone:727-767-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist