Provider Demographics
NPI:1902325574
Name:WRIGHT, JIMMY ALLAN
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:ALLAN
Last Name:WRIGHT
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 1:402 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:AL
Mailing Address - Zip Code:36027-1410
Mailing Address - Country:US
Mailing Address - Phone:334-695-0899
Mailing Address - Fax:
Practice Address - Street 1:3230 STADIUM TOWER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36082-0001
Practice Address - Country:US
Practice Address - Phone:334-670-3720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
AL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer