Provider Demographics
NPI:1356442636
Name:PROFFITT, JAMES LEWIS
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEWIS
Last Name:PROFFITT
Suffix:
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 1:2823 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5611
Mailing Address - Country:US
Mailing Address - Phone:731-293-9946
Mailing Address - Fax:
Practice Address - Street 1:2823 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5611
Practice Address - Country:US
Practice Address - Phone:731-293-9946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1618103TC0700X
TNPE1618101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441164Medicaid
TN3376955Medicare ID - Type UnspecifiedGROUP NUMBER