Healthcare Provider Details

I. General information

NPI: 1568889020
Provider Name (Legal Business Name): JASMINE WILEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COUNTY ROAD B
SHAWANO WI
54166-7072
US

IV. Provider business mailing address

122 E COLLEGE AVE STE 250
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 715-524-2161
  • Fax: 715-524-8164
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64844-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: