Provider Demographics
NPI:1831430826
Name:WHITEHEAD, JANTZEN WAYNE (MS)
Entity type:Individual
Prefix:MR
First Name:JANTZEN
Middle Name:WAYNE
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLTON
Mailing Address - State:FL
Mailing Address - Zip Code:32426
Mailing Address - Country:US
Mailing Address - Phone:850-693-9752
Mailing Address - Fax:
Practice Address - Street 1:2860 HIGHWAY 71 N
Practice Address - Street 2:SUITE A
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-482-0019
Practice Address - Fax:850-482-0015
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH10814101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health