Healthcare Provider Details

I. General information

NPI: 1891192563
Provider Name (Legal Business Name): JEREMY KULBETH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

39297 CRAWFORD RD
FRANKLINTON LA
70438-2907
US

V. Phone/Fax

Practice location:
  • Phone: 601-540-2972
  • Fax:
Mailing address:
  • Phone: 318-470-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0729
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: