MEDICARE: JESSICA LAUREN WYNN LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LCM678	MD
2	106H00000X	Marriage & Family Therapist	MSMFT.0000005	CO

General Provider Information

NPI Number	:	1053807313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LAUREN WYNN LMFT

Provider Business Mailing Address
First Line	:	5035 LANGDALE WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-7673
Country	:	US
Telephone Number	:	912-610-2107
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 E CHEYENNE MOUNTAIN BLVD STE 220
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3700
Country	:	US
Telephone Number	:	719-694-9739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	08/01/2022

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