Provider Demographics
NPI:1194989772
Name:JACKSON, WYNN K (MD)
Entity type:Individual
Prefix:DR
First Name:WYNN
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BENEDICT PL
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5358
Mailing Address - Country:US
Mailing Address - Phone:203-661-7575
Mailing Address - Fax:
Practice Address - Street 1:2 BENEDICT PL
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5358
Practice Address - Country:US
Practice Address - Phone:203-661-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0297592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry