Provider Demographics
NPI:1033881628
Name:CAMPBELL, JERRY WAYNE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:CAMPBELL
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 1:901 S ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-7003
Mailing Address - Country:US
Mailing Address - Phone:918-944-9970
Mailing Address - Fax:
Practice Address - Street 1:205 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-5201
Practice Address - Country:US
Practice Address - Phone:918-803-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist