Provider Demographics
NPI:1093430902
Name:EDGE, JEROME (CPC)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:EDGE
Suffix:
Gender:M
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HULBUSH LN APT 14
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-1036
Mailing Address - Country:US
Mailing Address - Phone:360-949-6489
Mailing Address - Fax:
Practice Address - Street 1:4120 MERIDIAN ST STE 220
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5575
Practice Address - Country:US
Practice Address - Phone:360-922-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61267837175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist