Healthcare Provider Details

I. General information

NPI: 1831893890
Provider Name (Legal Business Name): KHRYSTAL WHITLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6859 GABLE GROVE AVE
JACKSONVILLE FL
32217-3737
US

IV. Provider business mailing address

6859 GABLE GROVE AVE
JACKSONVILLE FL
32217-3737
US

V. Phone/Fax

Practice location:
  • Phone: 904-732-0771
  • Fax:
Mailing address:
  • Phone: 904-732-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW23802
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW23802
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW23802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: