Provider Demographics
NPI:1336734359
Name:WILLEY, JONATHAN WADE (PT)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WADE
Last Name:WILLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOVER AIR FORCE BASE
Mailing Address - State:DE
Mailing Address - Zip Code:19902-5003
Mailing Address - Country:US
Mailing Address - Phone:302-677-2568
Mailing Address - Fax:
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AIR FORCE BASE
Practice Address - State:DE
Practice Address - Zip Code:19902-5003
Practice Address - Country:US
Practice Address - Phone:302-677-2568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCP017653T225100000X
DEJ1-0014311225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist