Provider Demographics
NPI:1023541950
Name:WILKISON, JORDAN (LAC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WILKISON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-2152
Mailing Address - Country:US
Mailing Address - Phone:870-633-8092
Mailing Address - Fax:870-633-8358
Practice Address - Street 1:1521 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2152
Practice Address - Country:US
Practice Address - Phone:870-633-8092
Practice Address - Fax:870-633-8358
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1703195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health