Provider Demographics
NPI:1144455833
Name:WIXOM, JODY QUICK (MD)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:QUICK
Last Name:WIXOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JODY
Other - Middle Name:LYNNE
Other - Last Name:QUICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-8818
Mailing Address - Fax:
Practice Address - Street 1:1055 N 300 W STE 410
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3354
Practice Address - Country:US
Practice Address - Phone:801-357-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-25
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5187987-1205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation