Provider Demographics
NPI:1972632008
Name:WILEY, JENNIFER DENISE (CAS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:DENISE
Last Name:WILEY
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PARK BLVD UNIT 2504
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7243
Mailing Address - Country:US
Mailing Address - Phone:619-501-5023
Mailing Address - Fax:
Practice Address - Street 1:3969 4TH AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3165
Practice Address - Country:US
Practice Address - Phone:619-278-0795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)