Healthcare Provider Details

I. General information

NPI: 1326942061
Provider Name (Legal Business Name): DOUGLAS JEROME WILKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 AVENUE A NW STE 300
WINTER HAVEN FL
33881-4540
US

IV. Provider business mailing address

932 VAN DR
AUBURNDALE FL
33823-9478
US

V. Phone/Fax

Practice location:
  • Phone: 863-299-7787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH28687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: