Provider Demographics
NPI:1437414562
Name:WILKERSON, JENNIFER ANN (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-8600
Mailing Address - Fax:
Practice Address - Street 1:1505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462
Practice Address - Country:US
Practice Address - Phone:918-967-3368
Practice Address - Fax:918-967-4582
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV810651363LF0000X
OK110512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200054500BMedicaid