Provider Demographics
NPI:1225464480
Name:WHALEN, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:WHALEN
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 1:886 AACHEN AVE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907
Mailing Address - Country:US
Mailing Address - Phone:321-768-2453
Mailing Address - Fax:
Practice Address - Street 1:886 AACHEN AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-9342
Practice Address - Country:US
Practice Address - Phone:321-768-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL307117224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification