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General NPI Number Information
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NPI Number | 1265007546
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Entity Type | Individual
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Provider Name | JONATHAN M WILEY
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Gender | Male
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Dates
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Enumeration Date | 05/20/2021
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Last Update Date | 05/20/2021
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Provider Practice Location Address
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Address Line | 1520 NE RIDDELL RD STE 110
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City | BREMERTON
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State | WA
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Zip | 98310-3005
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Country | US
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Telephone | 360-288-7264
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Fax |
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Provider Business Mailing Address
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Address Line | 9711 DANWOOD LN NW APT 34
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City | SILVERDALE
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State | WA
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Zip | 98383-9148
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Country | US
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Telephone | 360-535-3287
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 61157956
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License Number State | WA
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