Provider Demographics
NPI:1851733190
Name:WILEY, JESSICA L (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:WILEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 FAY AVE
Mailing Address - Street 2:SUITE 525
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4885
Mailing Address - Country:US
Mailing Address - Phone:858-224-3387
Mailing Address - Fax:
Practice Address - Street 1:7590 FAY AVE
Practice Address - Street 2:SUITE 5252
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4885
Practice Address - Country:US
Practice Address - Phone:858-224-3387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207992225100000X
CA419292251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist