Provider Demographics
NPI:1871278044
Name:WILKERSON, JERRY LEE
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10170 HIGHWAY 76 S
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-6808
Mailing Address - Country:US
Mailing Address - Phone:901-813-8529
Mailing Address - Fax:
Practice Address - Street 1:10170 HIGHWAY 76 S
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-6808
Practice Address - Country:US
Practice Address - Phone:901-813-8529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)