Provider Demographics
NPI:1629621925
Name:WIXSON, KAITLYN SUE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:SUE
Last Name:WIXSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4914 CHURCHILL RD
Mailing Address - Street 2:
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251-9794
Mailing Address - Country:US
Mailing Address - Phone:517-392-8110
Mailing Address - Fax:
Practice Address - Street 1:330 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2121
Practice Address - Country:US
Practice Address - Phone:517-787-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional