Healthcare Provider Details

I. General information

NPI: 1952173031
Provider Name (Legal Business Name): JAKAYLA BRIEL WHITTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SONGTAN BLVD UNIT 2060 OSAN AB
APO AP
96278
US

IV. Provider business mailing address

PSC 3 BOX 5515
APO AP
96266-0056
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-2115
  • Fax:
Mailing address:
  • Phone: 803-667-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: