Provider Demographics
NPI:1144794348
Name:GREEN, JIMMMYE DALE JR (OTR/L,CEAS)
Entity Type:Individual
Prefix:
First Name:JIMMMYE
Middle Name:DALE
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:OTR/L,CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1843 HIGHWAY 4 E
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-9744
Mailing Address - Country:US
Mailing Address - Phone:662-544-2771
Mailing Address - Fax:
Practice Address - Street 1:2648 SEVIERVILLE RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-3643
Practice Address - Country:US
Practice Address - Phone:865-984-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003798225XE1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomicsGroup - Single Specialty