Healthcare Provider Details

I. General information

NPI: 1881837755
Provider Name (Legal Business Name): JAMIE L BACK REGISTERED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JAMIE L SHELTON REGISTERED

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

3701 REDDICK RD
PALMYRA TN
37142-2127
US

V. Phone/Fax

Practice location:
  • Phone: 270-956-0088
  • Fax:
Mailing address:
  • Phone: 931-624-9695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number8325
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: