Healthcare Provider Details

I. General information

NPI: 1144648254
Provider Name (Legal Business Name): JONATHAN WILCOXEN MT-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8524 BURNET RD APT 915
AUSTIN TX
78757-7060
US

IV. Provider business mailing address

8524 BURNET RD APT 915
AUSTIN TX
78757-7060
US

V. Phone/Fax

Practice location:
  • Phone: 309-338-2370
  • Fax:
Mailing address:
  • Phone: 309-338-2370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number10844
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: