Healthcare Provider Details

I. General information

NPI: 1992543169
Provider Name (Legal Business Name): JESSICA WYNN LYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7972 SE 13TH AVE # 107
PORTLAND OR
97202-6677
US

IV. Provider business mailing address

7972 SE 13TH AVE # 107
PORTLAND OR
97202-6677
US

V. Phone/Fax

Practice location:
  • Phone: 971-238-6363
  • Fax:
Mailing address:
  • Phone: 971-238-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10025423
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: