Healthcare Provider Details

I. General information

NPI: 1790216133
Provider Name (Legal Business Name): JEFFREY WYSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2819 CALKINS PL
BROOMFIELD CO
80020-5456
US

IV. Provider business mailing address

7723 O CONNOR RD
BOULDER CO
80303-4836
US

V. Phone/Fax

Practice location:
  • Phone: 720-310-0363
  • Fax:
Mailing address:
  • Phone: 720-310-0363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR0066582
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: