Provider Demographics
NPI:1356859805
Name:WILKERSON, CAROLINE (LAC)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:WILKERSON
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 1:1522 N HARLEM AVE APT 2N
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1245
Mailing Address - Country:US
Mailing Address - Phone:808-738-6038
Mailing Address - Fax:
Practice Address - Street 1:67 E OAK ST STE 3W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-6803
Practice Address - Country:US
Practice Address - Phone:708-406-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001359171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist