Healthcare Provider Details

I. General information

NPI: 1467371989
Provider Name (Legal Business Name): MR. JIMMY PROSS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UNION ST S STE LL224
CONCORD NC
28025-5059
US

IV. Provider business mailing address

6012 BAYFIELD PKWY STE 379
CONCORD NC
28027-7597
US

V. Phone/Fax

Practice location:
  • Phone: 980-357-3588
  • Fax: 972-695-4875
Mailing address:
  • Phone: 980-777-0091
  • Fax: 972-695-4875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: