Provider Demographics
NPI:1578285219
Name:WHITAKER, JEFFREY DANIEL (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DANIEL
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446A 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-2223
Mailing Address - Country:US
Mailing Address - Phone:903-283-0834
Mailing Address - Fax:
Practice Address - Street 1:1201 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2046
Practice Address - Country:US
Practice Address - Phone:971-251-9856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202213055NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health