Provider Demographics
NPI:1376854778
Name:WYNNE, JENNIFER (MA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 NEW MOHAWK RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-3244
Mailing Address - Country:US
Mailing Address - Phone:530-277-1270
Mailing Address - Fax:
Practice Address - Street 1:138 NEW MOHAWK RD
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-3244
Practice Address - Country:US
Practice Address - Phone:530-277-1270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist