Provider Demographics
NPI:1710674080
Name:WYNN, JILL J (LCSW)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:J
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 5TH AVE # 1983
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-2794
Mailing Address - Country:US
Mailing Address - Phone:253-648-0340
Mailing Address - Fax:206-673-8050
Practice Address - Street 1:220 5TH AVE FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-8017
Practice Address - Country:US
Practice Address - Phone:212-564-0480
Practice Address - Fax:833-464-5058
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0949741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical