Provider Demographics
NPI:1003414293
Name:WOOTEN, JACK WEAIR JR
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WEAIR
Last Name:WOOTEN
Suffix:JR
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 1:2612 W HEIMAN ST APT D38
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-1818
Mailing Address - Country:US
Mailing Address - Phone:615-686-5212
Mailing Address - Fax:
Practice Address - Street 1:2612 W HEIMAN ST APT D38
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-1818
Practice Address - Country:US
Practice Address - Phone:615-686-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2212225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist