Provider Demographics
NPI:1912408790
Name:WILEY, JASON (LAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WILEY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64-5280 PUU NANEA ST
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8125
Mailing Address - Country:US
Mailing Address - Phone:808-238-9409
Mailing Address - Fax:
Practice Address - Street 1:72-3996 HAWAII BELT RD
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-8608
Practice Address - Country:US
Practice Address - Phone:808-238-9409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1046171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist