Provider Demographics
NPI:1336457605
Name:WILKERSON, JENNY LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2554
Mailing Address - Country:US
Mailing Address - Phone:601-656-8331
Mailing Address - Fax:
Practice Address - Street 1:714 PECAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3402
Practice Address - Country:US
Practice Address - Phone:601-656-2545
Practice Address - Fax:601-656-2059
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist