Provider Demographics
NPI:1497303192
Name:WHITTAKER, JEREMY KYLE
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KYLE
Last Name:WHITTAKER
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 1:213 E PLUM ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47330-1214
Mailing Address - Country:US
Mailing Address - Phone:765-277-6271
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:888-291-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator