Healthcare Provider Details

I. General information

NPI: 1780774190
Provider Name (Legal Business Name): JERRY L WYCKOFF PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 11/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 COLLEGE BLVD. SUITE 250
OVERLAND PARK KS
66210-1944
US

IV. Provider business mailing address

7501 COLLEGE BLVD. SUITE 250
OVERLAND PARK KS
66210-1944
US

V. Phone/Fax

Practice location:
  • Phone: 913-451-8550
  • Fax: 913-469-5266
Mailing address:
  • Phone: 913-451-8550
  • Fax: 913-469-5266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberR0309
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: