Provider Demographics
NPI:1104052216
Name:ATKINS, JACK HOMER III (IDMT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:HOMER
Last Name:ATKINS
Suffix:III
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 POST AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37777-6223
Mailing Address - Country:US
Mailing Address - Phone:865-985-4277
Mailing Address - Fax:865-985-4273
Practice Address - Street 1:420 POST AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:TN
Practice Address - Zip Code:37777-6223
Practice Address - Country:US
Practice Address - Phone:865-985-4277
Practice Address - Fax:865-985-4273
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians