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General NPI Number Information
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NPI Number | 1346494366
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Entity Type | Individual
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Provider Name | JESSICA BRADLEY WILKERSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/05/2008
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Last Update Date | 05/08/2024
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Provider Practice Location Address
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Address Line | 305 S BROADWAY AVE STE 200
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City | TYLER
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State | TX
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Zip | 75702-7344
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Country | US
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Telephone | 903-939-9010
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Fax |
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Provider Business Mailing Address
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Address Line | 104 COCKRELL HILL RD
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City | OVILLA
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State | TX
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Zip | 75154-1465
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Country | US
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Telephone | 865-304-1045
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 5712
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 107536
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License Number State | TX
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