Healthcare Provider Details

I. General information

NPI: 1417496399
Provider Name (Legal Business Name): JERREL WYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SHADOWBROOK LN NE
HUNTSVILLE AL
35811-8203
US

IV. Provider business mailing address

222 SHADOWBROOK LN NE
HUNTSVILLE AL
35811-8203
US

V. Phone/Fax

Practice location:
  • Phone: 256-701-0998
  • Fax: 256-384-7648
Mailing address:
  • Phone: 256-701-0998
  • Fax: 256-384-7648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: