Provider Demographics
NPI:1174720445
Name:BRANNON, JIMMY DALE (COTA,L)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:DALE
Last Name:BRANNON
Suffix:
Gender:M
Credentials:COTA,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:KY
Mailing Address - Zip Code:42330
Mailing Address - Country:US
Mailing Address - Phone:270-754-5280
Mailing Address - Fax:
Practice Address - Street 1:313 MAIN
Practice Address - Street 2:
Practice Address - City:FORDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42343
Practice Address - Country:US
Practice Address - Phone:270-276-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA3397224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant