Provider Demographics
NPI:1740575158
Name:JACKIE W. WESTFALL D.O. LLC
Entity Type:Organization
Organization Name:JACKIE W. WESTFALL D.O. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WESTFALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-682-5332
Mailing Address - Street 1:322 RACETRACK RD NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-2546
Mailing Address - Country:US
Mailing Address - Phone:850-682-5332
Mailing Address - Fax:850-683-5333
Practice Address - Street 1:322 RACETRACK RD NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2546
Practice Address - Country:US
Practice Address - Phone:850-682-5332
Practice Address - Fax:850-683-5333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5855302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE93716Medicare UPIN
FL80464Medicare PIN