Provider Demographics
NPI:1336725290
Name:DUNITZ, JACKSON DAVID
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:DAVID
Last Name:DUNITZ
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 1:809 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4607
Mailing Address - Country:US
Mailing Address - Phone:843-692-4544
Mailing Address - Fax:843-692-1122
Practice Address - Street 1:1215 LEE ST # 800710
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-4607
Practice Address - Country:US
Practice Address - Phone:434-982-0629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101285611390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program