Provider Demographics
NPI:1053638874
Name:RAGON, JERRY LABRON
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LABRON
Last Name:RAGON
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 1:8 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKAMAUGA
Mailing Address - State:GA
Mailing Address - Zip Code:30707-1308
Mailing Address - Country:US
Mailing Address - Phone:423-802-9804
Mailing Address - Fax:877-259-6370
Practice Address - Street 1:8 W 8TH ST
Practice Address - Street 2:
Practice Address - City:CHICKAMAUGA
Practice Address - State:GA
Practice Address - Zip Code:30707-1308
Practice Address - Country:US
Practice Address - Phone:423-802-9804
Practice Address - Fax:877-259-6370
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6357171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445385OtherTNCARE PROVIDER NUMBER