Provider Demographics
NPI:1558186601
Name:WHITSON, IRA JOE SR
Entity type:Individual
Prefix:MR
First Name:IRA JOE
Middle Name:
Last Name:WHITSON
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7224 S RECOVERY RD
Mailing Address - Street 2:
Mailing Address - City:FRENCH CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95231-8901
Mailing Address - Country:US
Mailing Address - Phone:209-888-6595
Mailing Address - Fax:
Practice Address - Street 1:7224 S RECOVERY RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-8901
Practice Address - Country:US
Practice Address - Phone:209-888-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker