Healthcare Provider Details

I. General information

NPI: 1629621925
Provider Name (Legal Business Name): KAITLYN SUE WIXSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W MICHIGAN AVE
JACKSON MI
49201-2121
US

IV. Provider business mailing address

4914 CHURCHILL RD
LESLIE MI
49251-9794
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-7920
  • Fax:
Mailing address:
  • Phone: 517-392-8110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: