Provider Demographics
NPI:1164627626
Name:JERRY, ASHLEY V (PTA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:V
Last Name:JERRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 TROJAN RD
Mailing Address - Street 2:
Mailing Address - City:MONETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29105-9309
Mailing Address - Country:US
Mailing Address - Phone:803-295-8293
Mailing Address - Fax:
Practice Address - Street 1:2993 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3421
Practice Address - Country:US
Practice Address - Phone:803-939-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2096225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant