Provider Demographics
NPI:1942599097
Name:WYNN, JESSE RANDELL (PHD)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:RANDELL
Last Name:WYNN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3989 E ARAPAHOE RD STE 320B
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2077
Mailing Address - Country:US
Mailing Address - Phone:303-961-7983
Mailing Address - Fax:
Practice Address - Street 1:3989 E ARAPAHOE RD STE 320B
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122-2077
Practice Address - Country:US
Practice Address - Phone:303-961-7983
Practice Address - Fax:720-372-2291
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0103391101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health