Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 2212 | TN |
NPI | 1003414293 |
---|---|
Provider Name | Jack Weair Wooten JR. |
First Address | Nashville, TN 37208-1818 |
Second Address | Nashville, TN 37208-1818 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2020 |
Last Update Date | 12/10/2020 |