Healthcare Provider Details

I. General information

NPI: 1386178309
Provider Name (Legal Business Name): JACOB WILKERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 RIVERGATE LN UNIT 105
DURANGO CO
81301-7490
US

IV. Provider business mailing address

2950 CLEVELAND CLINIC BLVD
WESTON FL
33331-3625
US

V. Phone/Fax

Practice location:
  • Phone: 970-259-3020
  • Fax:
Mailing address:
  • Phone: 954-659-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number156204
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberDR.0070961
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: