Provider Demographics
NPI:1164054482
Name:WHITAKER, JACOLBY THOMAS
Entity Type:Individual
Prefix:
First Name:JACOLBY
Middle Name:THOMAS
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8830 STATE HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:TX
Mailing Address - Zip Code:75925-6018
Mailing Address - Country:US
Mailing Address - Phone:903-948-1074
Mailing Address - Fax:
Practice Address - Street 1:8830 STATE HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:TX
Practice Address - Zip Code:75925-6018
Practice Address - Country:US
Practice Address - Phone:903-948-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer