Provider Demographics
NPI:1205006756
Name:WILKERSON, TYRA G
Entity Type:Individual
Prefix:MRS
First Name:TYRA
Middle Name:G
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5776 SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8030
Mailing Address - Country:US
Mailing Address - Phone:904-448-4700
Mailing Address - Fax:904-448-4717
Practice Address - Street 1:8015 PARKER SCHOOL RD
Practice Address - Street 2:SUITE 160
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5172
Practice Address - Country:US
Practice Address - Phone:904-858-1963
Practice Address - Fax:904-858-1455
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist