Provider Demographics
NPI:1417496399
Name:WYNN, JERREL
Entity Type:Individual
Prefix:
First Name:JERREL
Middle Name:
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 1:222 SHADOWBROOK LN NE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-8203
Mailing Address - Country:US
Mailing Address - Phone:256-701-0998
Mailing Address - Fax:256-384-7648
Practice Address - Street 1:222 SHADOWBROOK LN NE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35811-8203
Practice Address - Country:US
Practice Address - Phone:256-701-0998
Practice Address - Fax:256-384-7648
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle