Provider Demographics
NPI:1619643368
Name:WYNER, JESSICA LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:WYNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LAUREN
Other - Last Name:DOCTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:12660 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3429
Mailing Address - Country:US
Mailing Address - Phone:818-755-0391
Mailing Address - Fax:
Practice Address - Street 1:12660 RIVERSIDE DR STE 225
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3469
Practice Address - Country:US
Practice Address - Phone:818-755-0265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily