Provider Demographics
NPI:1609291087
Name:WYANT, JESSYCA
Entity Type:Individual
Prefix:
First Name:JESSYCA
Middle Name:
Last Name:WYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27646 HI VIEW RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-6520
Mailing Address - Country:US
Mailing Address - Phone:303-588-0608
Mailing Address - Fax:
Practice Address - Street 1:27646 HI VIEW RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-6520
Practice Address - Country:US
Practice Address - Phone:303-588-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty