Provider Demographics
NPI:1760692909
Name:WHITLOCK, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12276 SAN JOSE BLVD STE 508
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8618
Mailing Address - Country:US
Mailing Address - Phone:904-886-3228
Mailing Address - Fax:904-886-3297
Practice Address - Street 1:12276 SAN JOSE BLVD STE 508
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8618
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:904-886-3297
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892199700Medicaid