Healthcare Provider Details

I. General information

NPI: 1184242778
Provider Name (Legal Business Name): JENNIFER LYNNE WYSONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 S DIXIE DR STE 260
DAYTON OH
45409-1542
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9058
US

V. Phone/Fax

Practice location:
  • Phone: 937-853-9061
  • Fax: 937-853-9069
Mailing address:
  • Phone: 419-695-8010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: