Healthcare Provider Details

I. General information

NPI: 1972752822
Provider Name (Legal Business Name): JACOB JUSTIN HUTZELL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 04/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 SAN JOSE BLVD STE # 2
JACKSONVILLE FL
32223-0754
US

IV. Provider business mailing address

11808 SAN JOSE BLVD STE # 2
JACKSONVILLE FL
32223-0754
US

V. Phone/Fax

Practice location:
  • Phone: 904-880-3271
  • Fax: 904-880-3273
Mailing address:
  • Phone: 904-880-3271
  • Fax: 904-880-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9481
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: