Healthcare Provider Details

I. General information

NPI: 1528757176
Provider Name (Legal Business Name): WHITAKER WELLNESS SPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 12/07/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8624 RIBBON FALLS LN
JACKSONVILLE FL
32244-4990
US

IV. Provider business mailing address

8624 RIBBON FALLS LN
JACKSONVILLE FL
32244-4990
US

V. Phone/Fax

Practice location:
  • Phone: 904-576-6868
  • Fax:
Mailing address:
  • Phone: 904-576-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: SHANTELL WHITAKER
Title or Position: OWNER/EMPLOYEE
Credential:
Phone: 904-576-6868