Provider Demographics
NPI:1285290908
Name:WYNDER, JACQUELINE A
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:WYNDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANNE
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AI HUA, WANG
Mailing Address - Street 1:791 E VINE ST APT 203
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6586
Mailing Address - Country:US
Mailing Address - Phone:253-861-0042
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E STE 2A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician