Provider Demographics
NPI:1659185635
Name:BALLARD-WITHERSPOON, JADELYN
Entity type:Individual
Prefix:
First Name:JADELYN
Middle Name:
Last Name:BALLARD-WITHERSPOON
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 1:26 RIVIERA ESTATES CT
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6566
Mailing Address - Country:US
Mailing Address - Phone:904-415-8844
Mailing Address - Fax:
Practice Address - Street 1:1621 ESPANOLA AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-1745
Practice Address - Country:US
Practice Address - Phone:904-415-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-393206106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician