Provider Demographics
NPI:1578513404
Name:WAXMAN, JILL LEVEY (PHD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:LEVEY
Last Name:WAXMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 HEATH LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5901
Mailing Address - Country:US
Mailing Address - Phone:770-833-0885
Mailing Address - Fax:770-565-7522
Practice Address - Street 1:105 ARNOLD MILL RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5027
Practice Address - Country:US
Practice Address - Phone:770-926-0016
Practice Address - Fax:770-926-0969
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002824103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA893674432AMedicaid