Provider Demographics
NPI:1215007026
Name:WILKERSON, JASON WAYNE (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:WAYNE
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 WILLOW STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172
Mailing Address - Country:US
Mailing Address - Phone:615-384-8435
Mailing Address - Fax:615-384-0855
Practice Address - Street 1:506 WILLOW STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172
Practice Address - Country:US
Practice Address - Phone:615-384-8435
Practice Address - Fax:615-384-0855
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000002007152W00000X
TNTN2007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943216Medicaid
TN3943216Medicaid
3943216Medicare ID - Type Unspecified