Healthcare Provider Details

I. General information

NPI: 1164689147
Provider Name (Legal Business Name): JACOB KALIKIMAKA WILKS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax:
Mailing address:
  • Phone: 602-277-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: