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General NPI Number Information
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NPI Number | 1265185169
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Entity Type | Individual
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Provider Name | LEJON CHARLES WILKERSON II
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Gender | Male
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Dates
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Enumeration Date | 01/31/2022
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Last Update Date | 10/27/2023
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Provider Practice Location Address
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Address Line | 3104 E CAMELBACK RD # 2414
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City | PHOENIX
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State | AZ
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Zip | 85016-4502
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Country | US
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Telephone | 928-504-4700
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Fax |
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Provider Business Mailing Address
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Address Line | 3104 E CAMELBACK RD # 2414
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City | PHOENIX
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State | AZ
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Zip | 85016-4502
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Country | US
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Telephone | 928-504-4700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | TEMP296086
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | RN273981
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License Number State | GA
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