Healthcare Provider Details

I. General information

NPI: 1962020438
Provider Name (Legal Business Name): JONATHAN SCOTT WYLLYS MA-LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NORWAY ST STE 1
GRAYLING MI
49738-1717
US

IV. Provider business mailing address

501 NORWAY ST STE 1
GRAYLING MI
49738-1717
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-7800
  • Fax: 989-348-5346
Mailing address:
  • Phone: 989-348-7800
  • Fax: 989-348-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: