Provider Demographics
NPI:1265185169
Name:WILKERSON, LEJON CHARLES II
Entity type:Individual
Prefix:
First Name:LEJON
Middle Name:CHARLES
Last Name:WILKERSON
Suffix:II
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 1:3104 E CAMELBACK RD # 2414
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4502
Mailing Address - Country:US
Mailing Address - Phone:928-504-4700
Mailing Address - Fax:
Practice Address - Street 1:3104 E CAMELBACK RD # 2414
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4502
Practice Address - Country:US
Practice Address - Phone:928-504-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN273981163WP0808X
AZTEMP296086363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health