MEDICARE: LAVANDER RONELL WILKERSON JR. PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	LPT-033428	AZ
2	225100000X	Physical Therapist	1359668	TX
3	225100000X	Physical Therapist	PT307345	CA
4	225100000X	Physical Therapist	PT35639	FL

General Provider Information

NPI Number	:	1265069793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAVANDER RONELL WILKERSON JR. PT

Provider Business Mailing Address
First Line	:	11451 WHISPERINGBROOK LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-1015
Country	:	US
Telephone Number	:	904-316-2693
Fax Number	:

Provider Business Practice Location Address
First Line	:	11451 WHISPERINGBROOK LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-1015
Country	:	US
Telephone Number	:	904-316-2693
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2020
Last Update Date	:	01/06/2026

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