Provider Demographics
NPI:1619534518
Name:DAVIS, JIMMIE LEE JR
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:LEE
Last Name:DAVIS
Suffix:JR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 BURTON AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4665
Mailing Address - Country:US
Mailing Address - Phone:936-671-0996
Mailing Address - Fax:
Practice Address - Street 1:505 S TIMBERLAND DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-4084
Practice Address - Country:US
Practice Address - Phone:936-671-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-26
Last Update Date:2019-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11803761744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty