| Doctor Name: | DR. JASON WISE |
| NPI Number: | 1023213006 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PSY.D. |
| License Number: | 6311 |
| Business Practice Address: | 165 Coleman Ave Watertown, NY - 136012217 |
| Business Phone Number: | 3157822061 |
| Business Fax Number: | |
| Mailing Address: | 165 Coleman Ave, WATERTOWN |
| State: | NY |
| Postal Code: | 136012217 |
| Phone Number: | 3157822061 |
| Fax Number: | |
| NPI Enumeration Date: | 06/19/2007 |
| NPI Last Update Date: | 06/21/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 6311 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OH |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |