Provider Demographics
NPI:1013627769
Name:WHITELY-JACKSON, JULIAN
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:WHITELY-JACKSON
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 1:871 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1731
Mailing Address - Country:US
Mailing Address - Phone:954-233-2121
Mailing Address - Fax:
Practice Address - Street 1:871 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-1731
Practice Address - Country:US
Practice Address - Phone:954-233-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS65186183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist