Provider Demographics
NPI:1376954321
Name:WILKENFIELD, JAYSON
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:WILKENFIELD
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 1:1012 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-4102
Mailing Address - Country:US
Mailing Address - Phone:916-446-3111
Mailing Address - Fax:916-446-3131
Practice Address - Street 1:1012 19TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-4102
Practice Address - Country:US
Practice Address - Phone:916-446-3111
Practice Address - Fax:916-446-3131
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13835103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist