Provider Demographics
NPI:1912966060
Name:PITTMAN, JEREMY H (PT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:H
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W POPLAR AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-6503
Mailing Address - Country:US
Mailing Address - Phone:901-850-5246
Mailing Address - Fax:
Practice Address - Street 1:622 W POPLAR AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-6503
Practice Address - Country:US
Practice Address - Phone:901-850-5426
Practice Address - Fax:901-850-5226
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4143886OtherBCBS
TN1511718Medicaid
TN7750939OtherAETNA
TN4143886OtherBCBS