Provider Demographics
NPI:1407150006
Name:WHITAKER, CHARLES DERRICK (DPT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DERRICK
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 PARK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-9638
Mailing Address - Country:US
Mailing Address - Phone:606-568-5724
Mailing Address - Fax:
Practice Address - Street 1:695 HIGHWAY 15 N STE 3
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-7005
Practice Address - Country:US
Practice Address - Phone:606-666-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist