Healthcare Provider Details

I. General information

NPI: 1336884675
Provider Name (Legal Business Name): JENNA WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ERWIN RD
DURHAM NC
27705-4699
US

IV. Provider business mailing address

1201 FIRST EDITION DR APT 1907
DURHAM NC
27703-0934
US

V. Phone/Fax

Practice location:
  • Phone: 919-681-2030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: