Provider Demographics
NPI:1124911144
Name:EASTMAN, JIMMY III
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:EASTMAN
Suffix:III
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:PO BOX 1191
Mailing Address - Street 2:
Mailing Address - City:KASILOF
Mailing Address - State:AK
Mailing Address - Zip Code:99610-1191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53132 BLUE RIBBON AVE
Practice Address - Street 2:
Practice Address - City:KASILOF
Practice Address - State:AK
Practice Address - Zip Code:99610
Practice Address - Country:US
Practice Address - Phone:910-742-8513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered