Provider Demographics
NPI:1811131980
Name:WHITTEN, JACKIE GLEN JR (IDMT-PARAMEDIC)
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:GLEN
Last Name:WHITTEN
Suffix:JR
Gender:M
Credentials:IDMT-PARAMEDIC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5700 ARNOLD ST
Mailing Address - Street 2:BLDG 5801
Mailing Address - City:TINKER AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73145-8105
Mailing Address - Country:US
Mailing Address - Phone:405-736-2820
Mailing Address - Fax:405-736-2677
Practice Address - Street 1:5700 ARNOLD ST
Practice Address - Street 2:BLDG 5801
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8105
Practice Address - Country:US
Practice Address - Phone:405-736-2820
Practice Address - Fax:405-736-2677
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians