Provider Demographics
NPI:1477068542
Name:WIGGINS, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WIGGINS
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 1:288 HARTWICK LN
Mailing Address - Street 2:
Mailing Address - City:ATKINS
Mailing Address - State:AR
Mailing Address - Zip Code:72823-8207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4025
Practice Address - Country:US
Practice Address - Phone:760-840-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician