Provider Demographics
NPI:1366084451
Name:PRIEST, THOMAS JEREMY
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JEREMY
Last Name:PRIEST
Suffix:
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 1:40 TOK JCT
Mailing Address - Street 2:
Mailing Address - City:ODEN
Mailing Address - State:AR
Mailing Address - Zip Code:71961-8148
Mailing Address - Country:US
Mailing Address - Phone:479-234-1147
Mailing Address - Fax:
Practice Address - Street 1:618 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-4605
Practice Address - Country:US
Practice Address - Phone:479-996-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4474225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant