1194983239 NPI number — JARVIS DWIGHT HERD

Table of content: JARVIS DWIGHT HERD (NPI 1194983239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194983239 NPI number — JARVIS DWIGHT HERD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERD
Provider First Name:
JARVIS
Provider Middle Name:
DWIGHT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194983239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 S HENDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-1017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-335-2583
Provider Business Mailing Address Fax Number:
817-335-2597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 E CORSICANA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75751-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-675-6877
Provider Business Practice Location Address Fax Number:
903-675-6876
Provider Enumeration Date:
05/27/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  50422 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)