Healthcare Provider Details

I. General information

NPI: 1114694569
Provider Name (Legal Business Name): JACOB RYAN WHITFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-7000
US

IV. Provider business mailing address

6526 FRIARS RD APT 111
SAN DIEGO CA
92108-1087
US

V. Phone/Fax

Practice location:
  • Phone: 727-317-7396
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: