Healthcare Provider Details

I. General information

NPI: 1265034839
Provider Name (Legal Business Name): JIWON HELEN WYMAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2372 MORSE AVE
IRVINE CA
92614-6234
US

IV. Provider business mailing address

454 LAS GALLINAS AVE # 2030
SAN RAFAEL CA
94903-3618
US

V. Phone/Fax

Practice location:
  • Phone: 714-410-6516
  • Fax:
Mailing address:
  • Phone: 714-410-6516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JIWON HELEN WYMAN
Title or Position: CEO
Credential: MD
Phone: 714-410-6516