Basic Information
| Provider Information | |||||||||
| NPI: | 1528095544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIESELER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 E SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | PY7276 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 076722100 | 05 | FL | MEDICAID |