Provider Demographics
NPI:1699963587
Name:WIXTED, JENNIFER MARY (LCSW, CAP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:WIXTED
Suffix:
Gender:F
Credentials:LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14139 TURNING LEAF DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7488
Mailing Address - Country:US
Mailing Address - Phone:321-258-0873
Mailing Address - Fax:
Practice Address - Street 1:300 S BAY AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2141
Practice Address - Country:US
Practice Address - Phone:407-321-4357
Practice Address - Fax:407-324-9055
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLSW98521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor