Provider Demographics
NPI:1033700398
Name:WILKERSON, JEREMIAH
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16265 CEDAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SALADO
Mailing Address - State:TX
Mailing Address - Zip Code:76571-5314
Mailing Address - Country:US
Mailing Address - Phone:817-729-7327
Mailing Address - Fax:
Practice Address - Street 1:16265 CEDAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:SALADO
Practice Address - State:TX
Practice Address - Zip Code:76571-5314
Practice Address - Country:US
Practice Address - Phone:817-729-7327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14667111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor