Provider Demographics
NPI:1497228761
Name:PERRY, ETHAN JACK
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JACK
Last Name:PERRY
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 1:4025 OAKWOOD DR APT 422
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-2380
Mailing Address - Country:US
Mailing Address - Phone:731-693-9283
Mailing Address - Fax:
Practice Address - Street 1:4025 OAKWOOD DR APT 422
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-2380
Practice Address - Country:US
Practice Address - Phone:731-693-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty