Healthcare Provider Details

I. General information

NPI: 1255345476
Provider Name (Legal Business Name): JARED STEPHEN HATHAWAY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 POPLAR AVE
MEMPHIS TN
38111-4692
US

IV. Provider business mailing address

1664 KIRBY PKWY.
MEMPHIS TN
38120
US

V. Phone/Fax

Practice location:
  • Phone: 901-454-1234
  • Fax: 901-454-0606
Mailing address:
  • Phone: 574-527-2283
  • Fax: 901-454-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number111N00000X
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: