Provider Demographics
NPI:1215354212
Name:WYLIE, JESSICA M (COTA/L/CASE MANAGER)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:WYLIE
Suffix:
Gender:F
Credentials:COTA/L/CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 W ODELL AVE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-4777
Mailing Address - Country:US
Mailing Address - Phone:307-797-0060
Mailing Address - Fax:
Practice Address - Street 1:1611 W ODELL AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-4777
Practice Address - Country:US
Practice Address - Phone:307-797-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator