Healthcare Provider Details

I. General information

NPI: 1245308956
Provider Name (Legal Business Name): JASON DOMINIC WILKERSON BA, MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W SECOND ST
LONOKE AR
72086
US

IV. Provider business mailing address

8018 DANWOOD DR
LITTLE ROCK AR
72204-8312
US

V. Phone/Fax

Practice location:
  • Phone: 501-676-5968
  • Fax: 501-676-3152
Mailing address:
  • Phone: 501-951-3348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: