Healthcare Provider Details

I. General information

NPI: 1922433200
Provider Name (Legal Business Name): WHITNEY L BERRY CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 BUCK CREEK RD
JACKSON GA
30233-6522
US

IV. Provider business mailing address

162 BUCK CREEK RD
JACKSON GA
30233-6522
US

V. Phone/Fax

Practice location:
  • Phone: 210-793-0904
  • Fax:
Mailing address:
  • Phone: 210-793-0904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number14-4655
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number144655
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: