MEDICARE: DR. JACQUELINE W WYNN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	P.5677	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730101437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE W WYNN PH.D.

Provider Business Mailing Address
First Line	:	700 CHILDRENS DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43205-2639
Country	:	US
Telephone Number	:	614-722-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	189 W SCHROCK RD
Second Line	:
City	:	WESTERVILLE
State	:	OH
Zip	:	43081-2890
Country	:	US
Telephone Number	:	614-355-7500
Fax Number	:	614-355-7533

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	04/23/2025

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