Provider Demographics
NPI:1619368941
Name:SULLIVAN, JIMMY BRIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:BRIAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 RICE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3223
Mailing Address - Country:US
Mailing Address - Phone:903-597-9021
Mailing Address - Fax:903-597-0840
Practice Address - Street 1:1540 RICE RD STE 400
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3223
Practice Address - Country:US
Practice Address - Phone:903-597-9021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12808111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX583300AC3ZOtherMEDICARE