Healthcare Provider Details

I. General information

NPI: 1073607362
Provider Name (Legal Business Name): JIMMY HARALSON WOOD JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 PRINCE AVE
ATHENS GA
30606-6030
US

IV. Provider business mailing address

PO BOX 8467
JACKSON WY
83002-8467
US

V. Phone/Fax

Practice location:
  • Phone: 706-548-7300
  • Fax:
Mailing address:
  • Phone: 307-733-5577
  • Fax: 307-733-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT007333
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: