Provider Demographics
NPI:1639326218
Name:WILCOX, TIMOTHY JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JACK
Last Name:WILCOX
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 1:2915 REED AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2769
Mailing Address - Country:US
Mailing Address - Phone:208-590-3540
Mailing Address - Fax:
Practice Address - Street 1:FE WARREN AFB MHC
Practice Address - Street 2:6900 ALDEN DRIVE
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-3913
Practice Address - Country:US
Practice Address - Phone:307-773-2998
Practice Address - Fax:307-773-4721
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008100103TC0700X
MT371103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical