Provider Demographics
NPI:1538840152
Name:WILEY, JACKIE LYNN ANN (LSW)
Entity type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN ANN
Last Name:WILEY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:OH
Mailing Address - Zip Code:44214-9777
Mailing Address - Country:US
Mailing Address - Phone:330-407-1794
Mailing Address - Fax:
Practice Address - Street 1:104 SPINK ST
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-3652
Practice Address - Country:US
Practice Address - Phone:330-264-8498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2308934104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker