Provider Demographics
NPI:1508253733
Name:OVERSTREET, JIMMIE
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:
Last Name:OVERSTREET
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 1:9010 149TH ST
Mailing Address - Street 2:APT 1B
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-3956
Mailing Address - Country:US
Mailing Address - Phone:347-770-1106
Mailing Address - Fax:
Practice Address - Street 1:236 2ND AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2704
Practice Address - Country:US
Practice Address - Phone:212-683-8905
Practice Address - Fax:212-683-8906
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY497489041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist