Provider Demographics
NPI:1548303563
Name:STOUT, JIMMY DALE (BA CHAPLAIN)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:DALE
Last Name:STOUT
Suffix:
Gender:M
Credentials:BA CHAPLAIN
Other - Prefix:MR
Other - First Name:JIMMY
Other - Middle Name:DALE
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA CHAPLAIN
Mailing Address - Street 1:8960 N AGATE PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-9418
Mailing Address - Country:US
Mailing Address - Phone:520-241-8608
Mailing Address - Fax:
Practice Address - Street 1:8960 N AGATE PLACE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742
Practice Address - Country:US
Practice Address - Phone:520-241-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171R00000XOther Service ProvidersInterpreter