Provider Demographics
NPI:1689794828
Name:WILKERSON, TRAVIS (LPC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:70 BATESVILLE BLVD STE C
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-8972
Practice Address - Country:US
Practice Address - Phone:870-793-3199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0201006101YM0800X
ARP0606035101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR228377719Medicaid