Provider Demographics
NPI:1518350255
Name:MALONE, JEREMY JINI
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JINI
Last Name:MALONE
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 1:100 EAST UNIVERSITY 8002
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754
Mailing Address - Country:US
Mailing Address - Phone:901-262-0851
Mailing Address - Fax:
Practice Address - Street 1:100 EAST UNIVERSITY
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71754
Practice Address - Country:US
Practice Address - Phone:901-262-0851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer