Provider Demographics
NPI:1225589914
Name:WYNNE, JEAN M (LCSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:WYNNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 APACHE PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-1328
Mailing Address - Country:US
Mailing Address - Phone:203-645-3814
Mailing Address - Fax:
Practice Address - Street 1:16 APACHE PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CT
Practice Address - Zip Code:06878-1328
Practice Address - Country:US
Practice Address - Phone:203-645-3814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084819-11041C0700X
CT0108811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical