Provider Demographics
NPI:1477102192
Name:CHULLA, JAKE N
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:N
Last Name:CHULLA
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 1:9823 TAPESTRY PARK CIR UNIT 503
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-9239
Mailing Address - Country:US
Mailing Address - Phone:727-953-0750
Mailing Address - Fax:
Practice Address - Street 1:5858 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2223
Practice Address - Country:US
Practice Address - Phone:904-721-3410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62872183500000X
FLPSI38313390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program