Healthcare Provider Details

I. General information

NPI: 1124820105
Provider Name (Legal Business Name): MR. TAYLOR JACK HELMBOLDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. TAYLOR JACK BOLDT

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MADISON AVE
MEMPHIS TN
38103-3438
US

IV. Provider business mailing address

371 BUBBY DR
COLLIERVILLE TN
38017-1025
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-5500
  • Fax:
Mailing address:
  • Phone: 865-803-6282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: