Basic Information
Provider Information | |||||||||
NPI: | 1144794348 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | JIMMMYE | ||||||||
MiddleName: | DALE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | OTR/L,CEAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1843 HIGHWAY 4 E | ||||||||
Address2: |   | ||||||||
City: | HOLLY SPRINGS | ||||||||
State: | MS | ||||||||
PostalCode: | 386359744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6625442771 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2648 SEVIERVILLE RD | ||||||||
Address2: |   | ||||||||
City: | MARYVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378043643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8659841660 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2019 | ||||||||
LastUpdateDate: | 01/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XE1200X | 0000003798 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics |
No ID Information.