Provider Demographics
NPI:1548932858
Name:WILSON, JYKEDRIN DANTREL
Entity type:Individual
Prefix:
First Name:JYKEDRIN
Middle Name:DANTREL
Last Name:WILSON
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 1:303 BRYSON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TN
Mailing Address - Zip Code:38474-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 BRYSON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TN
Practice Address - Zip Code:38474-1308
Practice Address - Country:US
Practice Address - Phone:313-878-5288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program