Provider Demographics
NPI:1043575301
Name:COY, JERRY WALTER (LMT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WALTER
Last Name:COY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44640 W YUCCA LN
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-4036
Mailing Address - Country:US
Mailing Address - Phone:602-770-0263
Mailing Address - Fax:
Practice Address - Street 1:44400 W HONEYCUTT RD
Practice Address - Street 2:STE 101
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-2944
Practice Address - Country:US
Practice Address - Phone:602-770-0263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-05220173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist