Provider Demographics
NPI:1194246306
Name:WHIDDEN, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WHIDDEN
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 1:501 HARBOR BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 HARBOR BLVD STE C
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2348
Practice Address - Country:US
Practice Address - Phone:850-654-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12229111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor