Provider Demographics
NPI:1316496250
Name:WEATHERLY, JIMMY CLYCE JR
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:CLYCE
Last Name:WEATHERLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 VISCOUNT AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-6023
Mailing Address - Country:US
Mailing Address - Phone:901-779-4199
Mailing Address - Fax:901-779-7103
Practice Address - Street 1:3840 VISCOUNT AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6023
Practice Address - Country:US
Practice Address - Phone:901-779-4199
Practice Address - Fax:901-779-7103
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies