Provider Demographics
NPI:1194377903
Name:WHITTALL, JESSY EUGENE WARREN
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:EUGENE WARREN
Last Name:WHITTALL
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 1:4389 BEAUFORT RD
Mailing Address - Street 2:
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532
Mailing Address - Country:US
Mailing Address - Phone:252-466-0921
Mailing Address - Fax:
Practice Address - Street 1:4389 BEAFORT RD
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532
Practice Address - Country:US
Practice Address - Phone:252-466-0921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman