Provider Demographics
NPI:1659424455
Name:MASK, JIMMIE LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:LEE
Last Name:MASK
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 1:825 MEMORIAL BLVD N
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2418
Mailing Address - Country:US
Mailing Address - Phone:276-632-8385
Mailing Address - Fax:276-632-9736
Practice Address - Street 1:825 MEMORIAL BLVD N
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2418
Practice Address - Country:US
Practice Address - Phone:276-632-8385
Practice Address - Fax:276-632-9736
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0000158111N00000X
FL00002247111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA075006OtherANTHEM INS COMPANY
VA350930384Medicare ID - Type Unspecified