Healthcare Provider Details

I. General information

NPI: 1063002236
Provider Name (Legal Business Name): JEROMY WHYTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 SOUTHWEST 4TH STREET UNIT 6
CAPE CORAL FL
33991-1984
US

IV. Provider business mailing address

18031 SW 136TH CT
MIAMI FL
33177-7145
US

V. Phone/Fax

Practice location:
  • Phone: 239-910-0712
  • Fax:
Mailing address:
  • Phone: 305-333-9230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: