1972613883 NPI number — JEREMIAH WAKEFIELD PT

Table of content: JEREMIAH WAKEFIELD PT (NPI 1972613883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972613883 NPI number — JEREMIAH WAKEFIELD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAKEFIELD
Provider First Name:
JEREMIAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972613883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 681478
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-1478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-591-6590
Provider Business Mailing Address Fax Number:
615-591-6601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 LUTHER RD
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
DICKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37055-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-740-9782
Provider Business Practice Location Address Fax Number:
615-740-8510
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7400 . This is a "LICENSE#" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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