Provider Demographics
NPI:1699187534
Name:SHUPE, JIMMY MAURICE (HIS)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:MAURICE
Last Name:SHUPE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4746 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1308
Mailing Address - Country:US
Mailing Address - Phone:903-561-8774
Mailing Address - Fax:903-561-8787
Practice Address - Street 1:4746 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1308
Practice Address - Country:US
Practice Address - Phone:903-561-8774
Practice Address - Fax:903-561-8787
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50685237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist