Provider Demographics
NPI:1891192563
Name:KULBETH, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:KULBETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39297 CRAWFORD RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-2907
Mailing Address - Country:US
Mailing Address - Phone:318-470-8887
Mailing Address - Fax:
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-540-2972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT07292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer