MEDICARE: KHRYSTAL WHITLOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1041S0200X	School Social Worker
2	104100000X	Social Worker
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1831893890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHRYSTAL WHITLOCK

Provider Business Mailing Address
First Line	:	1303 MULL ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-6814
Country	:	US
Telephone Number	:	904-732-0771
Fax Number	:

Provider Business Practice Location Address
First Line	:	1303 MULL ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-6814
Country	:	US
Telephone Number	:	904-732-0771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	03/27/2023

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Directions to “ KHRYSTAL WHITLOCK ” Practice Location

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