Provider Demographics
NPI:1265034839
Name:JIWON HELEN WYMAN MD PC
Entity Type:Organization
Organization Name:JIWON HELEN WYMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JIWON HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-410-6516
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:
Practice Address - Street 1:2372 MORSE AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6234
Practice Address - Country:US
Practice Address - Phone:714-410-6516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health