Healthcare Provider Details

I. General information

NPI: 1861844367
Provider Name (Legal Business Name): JACQULYNE HELENE SYLVIA WYNNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQULYNE HELENE SYLVIA DO

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 EL CAMINO AVE
SACRAMENTO CA
95815-2530
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-642-1867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19051
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number19051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: