Provider Demographics
NPI:1518294149
Name:MUSGROW, JIMMIE (ETC)
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:
Last Name:MUSGROW
Suffix:
Gender:M
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COMMANDER, 121 GH/USAMEDDAC-KOREA
Mailing Address - Street 2:ATTN: MCKT-CS-QM (CREDENTIALS)
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5281
Mailing Address - Country:US
Mailing Address - Phone:8227-917-3244
Mailing Address - Fax:8227-917-8110
Practice Address - Street 1:121 GENERAL HOSPITAL
Practice Address - Street 2:ATTN: MCKT-CS-QM (CREDENTIALS)
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5281
Practice Address - Country:US
Practice Address - Phone:8227-917-3244
Practice Address - Fax:8227-917-8110
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4222-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health