Provider Demographics
NPI:1053005165
Name:WYMORE, JENNY (CLD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:WYMORE
Suffix:
Gender:F
Credentials:CLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 CALABRIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-5659
Mailing Address - Country:US
Mailing Address - Phone:915-490-6486
Mailing Address - Fax:
Practice Address - Street 1:1311 CALABRIA ST
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-5659
Practice Address - Country:US
Practice Address - Phone:915-490-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4-202319374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula