Healthcare Provider Details

I. General information

NPI: 1003519851
Provider Name (Legal Business Name): WHITNEY ELIZABETH JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WHITNEY ELIZABETH GRIER MD

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462626 STATE ROAD 200 STE 100
YULEE FL
32097-5513
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-225-3824
  • Fax: 904-390-7440
Mailing address:
  • Phone: 904-202-3860
  • Fax: 904-202-3846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME182789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: