Provider Demographics
NPI:1457668618
Name:WHITED, JAMES C JR (ARNP, LMT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:WHITED
Suffix:JR
Gender:M
Credentials:ARNP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 ELLIS RD S STE 114A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3574
Mailing Address - Country:US
Mailing Address - Phone:904-384-9007
Mailing Address - Fax:904-384-2899
Practice Address - Street 1:592 ELLIS RD S STE 114A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3574
Practice Address - Country:US
Practice Address - Phone:904-384-9007
Practice Address - Fax:904-384-2899
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29917225700000X
FLARNP9279002208D00000X, 363L00000X, 363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY09P8OtherBLUE CROSS
FL004512700Medicaid