Healthcare Provider Details

I. General information

NPI: 1386555647
Provider Name (Legal Business Name): TIMOTHEA WHITEHURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIA WHITEHURST

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 HIGHWOOD DR
JACKSONVILLE FL
32216-3615
US

IV. Provider business mailing address

7643 GATE PKWY # 104-333
JACKSONVILLE FL
32256-3092
US

V. Phone/Fax

Practice location:
  • Phone: 904-514-3562
  • Fax:
Mailing address:
  • Phone: 904-514-3562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: