Provider Demographics
NPI:1023226115
Name:WIXOM, JEAN M (PHD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:M
Last Name:WIXOM
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 1:332 E WASHINGTON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2062
Mailing Address - Country:US
Mailing Address - Phone:734-662-7513
Mailing Address - Fax:
Practice Address - Street 1:332 E WASHINGTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2062
Practice Address - Country:US
Practice Address - Phone:734-662-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical