Provider Demographics
NPI:1205666724
Name:WILEY, JENNIFER (RN, LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 PARKGATE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4385
Mailing Address - Country:US
Mailing Address - Phone:573-889-9864
Mailing Address - Fax:
Practice Address - Street 1:529 PARKGATE DR
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4385
Practice Address - Country:US
Practice Address - Phone:573-889-9864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007084163W00000X
MO2020040293225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered Nurse