Provider Demographics
NPI:1053807313
Name:WYNN, JESSICA LAUREN (LMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:WYNN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5035 LANGDALE WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7673
Mailing Address - Country:US
Mailing Address - Phone:912-610-2107
Mailing Address - Fax:
Practice Address - Street 1:225 E CHEYENNE MOUNTAIN BLVD STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3700
Practice Address - Country:US
Practice Address - Phone:719-694-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM678106H00000X
COMSMFT.0000005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist