Basic Information
| Provider Information | |||||||||
| NPI: | 1336734359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLEY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 179 | ||||||||
| Address2: | |||||||||
| City: | FOREST HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210500179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1073465564 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2304 E CHURCHVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210151721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107346556 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2021 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0014311 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 28307 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.