Provider Demographics
NPI:1164913398
Name:WYNN, JASMEAN ELICE
Entity Type:Individual
Prefix:MS
First Name:JASMEAN
Middle Name:ELICE
Last Name:WYNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ELLINWOOD DR APT 136
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2438
Mailing Address - Country:US
Mailing Address - Phone:925-826-4773
Mailing Address - Fax:
Practice Address - Street 1:400 29TH ST STE 204
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3547
Practice Address - Country:US
Practice Address - Phone:415-748-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician