Provider Demographics
NPI:1114923562
Name:WAKIM, JEAN-CLAUDE I (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN-CLAUDE
Middle Name:I
Last Name:WAKIM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16200 N. DALLAS PKWY
Mailing Address - Street 2:STE 280
Mailing Address - City:DALLAS
Mailing Address - State:TN
Mailing Address - Zip Code:75248-2684
Mailing Address - Country:US
Mailing Address - Phone:972-768-2290
Mailing Address - Fax:972-335-7642
Practice Address - Street 1:16200 N. DALLAS PKWY
Practice Address - Street 2:STE 280
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-2684
Practice Address - Country:US
Practice Address - Phone:972-768-2290
Practice Address - Fax:972-335-7642
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
TX25106103TA0700X, 103TC0700X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N60RMedicare ID - Type Unspecified