Provider Demographics
NPI:1881837755
Name:BACK, JAMIE L (REGISTERED)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:L
Last Name:BACK
Suffix:
Gender:F
Credentials:REGISTERED
Other - Prefix:MRS
Other - First Name:JAMIE
Other - Middle Name:L
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED
Mailing Address - Street 1:3701 REDDICK RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:TN
Mailing Address - Zip Code:37142-2127
Mailing Address - Country:US
Mailing Address - Phone:931-624-9695
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-956-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8325246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG