Provider Demographics
NPI:1275983371
Name:JETER-WILCOX, KIZZY KAI (MSW)
Entity Type:Individual
Prefix:MRS
First Name:KIZZY
Middle Name:KAI
Last Name:JETER-WILCOX
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1492 NORTH AVE
Mailing Address - Street 2:APT 105
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2663
Mailing Address - Country:US
Mailing Address - Phone:203-543-6855
Mailing Address - Fax:
Practice Address - Street 1:1492 NORTH AVE
Practice Address - Street 2:APT 105
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2663
Practice Address - Country:US
Practice Address - Phone:203-543-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker