Healthcare Provider Details

I. General information

NPI: 1952810525
Provider Name (Legal Business Name): JAY WILES PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 03/30/2025
Certification Date: 03/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 BRYCE CIR STE C
SIMPSONVILLE SC
29681-4842
US

IV. Provider business mailing address

205 BRYCE CIR STE C
SIMPSONVILLE SC
29681-4842
US

V. Phone/Fax

Practice location:
  • Phone: 864-420-3605
  • Fax:
Mailing address:
  • Phone: 864-420-3605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number0810005806
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: