Provider Demographics
NPI:1811505548
Name:WYLIE, JEFFREY THOMAS (LCSW)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:WYLIE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BYRON DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-0963
Mailing Address - Country:US
Mailing Address - Phone:270-556-8715
Mailing Address - Fax:
Practice Address - Street 1:2204 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3242
Practice Address - Country:US
Practice Address - Phone:270-777-4490
Practice Address - Fax:866-441-1083
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical