Provider Demographics
NPI:1740489061
Name:WIXOM, JOLENE M (LMP)
Entity type:Individual
Prefix:MISS
First Name:JOLENE
Middle Name:M
Last Name:WIXOM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 E GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-3035
Mailing Address - Country:US
Mailing Address - Phone:509-280-6615
Mailing Address - Fax:
Practice Address - Street 1:1103 E GARLAND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-3035
Practice Address - Country:US
Practice Address - Phone:509-280-6615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist