| Doctor Name: | JENNA WYCKOFF |
| NPI Number: | 1124445895 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 0991101 |
| Business Practice Address: | 2317 San Juan Ave La Junta, CO - 810503340 |
| Business Phone Number: | 7193832325 |
| Business Fax Number: | 7193832327 |
| Mailing Address: | 2317 San Juan Ave, LA JUNTA |
| State: | CO |
| Postal Code: | 810503340 |
| Phone Number: | 7193832325 |
| Fax Number: | 7193832327 |
| NPI Enumeration Date: | 03/19/2014 |
| NPI Last Update Date: | 03/19/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 0991101 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |