Provider Demographics
NPI:1396376257
Name:DOOLITTLE, JIMMY GLENN
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:GLENN
Last Name:DOOLITTLE
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 1:4319 W RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1407
Mailing Address - Country:US
Mailing Address - Phone:228-239-4249
Mailing Address - Fax:
Practice Address - Street 1:990 MIGEON AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4555
Practice Address - Country:US
Practice Address - Phone:203-525-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1622101YP2500X
CT005290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty