Provider Demographics
NPI:1568719516
Name:HOWARD, JIMMY JR (PTA)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:HOWARD
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 MIRACLE MILE STE 107
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7553
Mailing Address - Country:US
Mailing Address - Phone:928-444-8168
Mailing Address - Fax:928-444-8169
Practice Address - Street 1:2585 MIRACLE MILE STE 107
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7553
Practice Address - Country:US
Practice Address - Phone:928-444-8168
Practice Address - Fax:928-444-8169
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9910A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant