Healthcare Provider Details

I. General information

NPI: 1619643368
Provider Name (Legal Business Name): JESSICA LAUREN WYNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LAUREN DOCTOR NP

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 RIVERSIDE DR STE 225
NORTH HOLLYWOOD CA
91607-3469
US

IV. Provider business mailing address

12660 RIVERSIDE DR
NORTH HOLLYWOOD CA
91607-3429
US

V. Phone/Fax

Practice location:
  • Phone: 818-755-0265
  • Fax:
Mailing address:
  • Phone: 818-755-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017840
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: