Provider Demographics
NPI:1922029412
Name:WILLEY, JAY WARREN (DO)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:WARREN
Last Name:WILLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 JACOB ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2009
Mailing Address - Country:US
Mailing Address - Phone:208-637-8146
Mailing Address - Fax:
Practice Address - Street 1:495 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4531
Practice Address - Country:US
Practice Address - Phone:208-478-7422
Practice Address - Fax:208-478-1515
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDG63436Medicare UPIN