Provider Demographics
NPI:1245308956
Name:WILKERSON, JASON DOMINIC (BA, MHPP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DOMINIC
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:BA, MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8018 DANWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-8312
Mailing Address - Country:US
Mailing Address - Phone:501-951-3348
Mailing Address - Fax:
Practice Address - Street 1:201 W SECOND ST
Practice Address - Street 2:
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086
Practice Address - Country:US
Practice Address - Phone:501-676-5968
Practice Address - Fax:501-676-3152
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
AR3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant