Provider Demographics
NPI:1457429094
Name:WILEY, JILL MARIE (OTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:WILEY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N12041 BREED RD
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-9539
Mailing Address - Country:US
Mailing Address - Phone:715-823-3983
Mailing Address - Fax:
Practice Address - Street 1:1256 BRANDY LAKE RD
Practice Address - Street 2:
Practice Address - City:ARBOR VITAE
Practice Address - State:WI
Practice Address - Zip Code:54568-0827
Practice Address - Country:US
Practice Address - Phone:715-356-9729
Practice Address - Fax:715-358-5209
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI518-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant