Healthcare Provider Details

I. General information

NPI: 1982129177
Provider Name (Legal Business Name): JORDAN WIXOM LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2267 TETON PLZ
IDAHO FALLS ID
83404-6486
US

IV. Provider business mailing address

2267 TETON PLZ
IDAHO FALLS ID
83404-6486
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-0140
  • Fax:
Mailing address:
  • Phone: 208-522-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-7628
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: