Healthcare Provider Details

I. General information

NPI: 1518411529
Provider Name (Legal Business Name): JOHN ELGIN WILKAITIS, MD, MS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N STE 234
JACKSON MS
39211-5932
US

IV. Provider business mailing address

3531 LAKELAND DR STE 1052
FLOWOOD MS
39232-8049
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-8531
  • Fax:
Mailing address:
  • Phone: 601-982-8531
  • Fax: 601-982-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901668
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN ELGIN WILKAITIS
Title or Position: OWNER
Credential: MD
Phone: 601-829-4170