Provider Demographics
NPI:1063912335
Name:WYLY, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WYLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 N 1165 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-6400
Mailing Address - Country:US
Mailing Address - Phone:801-389-2381
Mailing Address - Fax:
Practice Address - Street 1:1159 N 1165 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-6400
Practice Address - Country:US
Practice Address - Phone:801-389-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10108693-6018101YA0400X
UT10108693-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)