Provider Demographics
NPI:1043746621
Name:WYMAN, JIWON HELEN (MD)
Entity Type:Individual
Prefix:
First Name:JIWON HELEN
Middle Name:
Last Name:WYMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JIWON
Other - Middle Name:HELEN
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:454 LAS GALLINAS AVE # 2030
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3618
Mailing Address - Country:US
Mailing Address - Phone:714-410-6516
Mailing Address - Fax:714-274-7568
Practice Address - Street 1:8300 UTICA AVE STE 245
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3852
Practice Address - Country:US
Practice Address - Phone:909-989-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD614259942084P0800X, 2084P0804X
CAA1592142084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry