Provider Demographics
NPI:1093407892
Name:ROBB, JERRY JACK
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:JACK
Last Name:ROBB
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 1:4150 WOODHILL DR
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:MN
Mailing Address - Zip Code:55357-9558
Mailing Address - Country:US
Mailing Address - Phone:612-481-9675
Mailing Address - Fax:
Practice Address - Street 1:4150 WOODHILL DR
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:MN
Practice Address - Zip Code:55357-9558
Practice Address - Country:US
Practice Address - Phone:612-481-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications