Healthcare Provider Details

I. General information

NPI: 1750200358
Provider Name (Legal Business Name): WISNER JEAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 FOREST HILL BLVD
WEST PALM BEACH FL
33406-5808
US

IV. Provider business mailing address

1116 OAKWATER DR
ROYAL PALM BEACH FL
33411-6104
US

V. Phone/Fax

Practice location:
  • Phone: 561-255-0728
  • Fax: 959-644-9342
Mailing address:
  • Phone: 561-255-0728
  • Fax: 959-644-9342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2999996845
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: