Healthcare Provider Details

I. General information

NPI: 1265185169
Provider Name (Legal Business Name): LEJON CHARLES WILKERSON II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 10/27/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 E CAMELBACK RD # 2414
PHOENIX AZ
85016-4502
US

IV. Provider business mailing address

3104 E CAMELBACK RD # 2414
PHOENIX AZ
85016-4502
US

V. Phone/Fax

Practice location:
  • Phone: 928-504-4700
  • Fax:
Mailing address:
  • Phone: 928-504-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberTEMP296086
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN273981
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: