Provider Demographics
NPI:1831593748
Name:WYNN, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WYNN
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 1:201 E MAIN DR STE 600
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79901-2226
Mailing Address - Country:US
Mailing Address - Phone:915-887-3410
Mailing Address - Fax:
Practice Address - Street 1:8730 BOEING
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2226
Practice Address - Country:US
Practice Address - Phone:915-887-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NMSWB-2023-0994104100000X
TX110666104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health