Provider Demographics
NPI:1154490142
Name:CARTER, JERRY WAYNE (ATC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:CARTER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 CALLE DE CASTELAR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-1290
Mailing Address - Country:US
Mailing Address - Phone:185-093-9574
Mailing Address - Fax:185-093-9574
Practice Address - Street 1:2200 CALLE DE CASTELAR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-1290
Practice Address - Country:US
Practice Address - Phone:185-093-9574
Practice Address - Fax:185-093-9574
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL2232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer