Provider Demographics
NPI:1164775268
Name:COLLINS, JERRY LYNN (DPH)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1829
Mailing Address - Country:US
Mailing Address - Phone:423-337-2829
Mailing Address - Fax:423-337-5574
Practice Address - Street 1:902 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-1829
Practice Address - Country:US
Practice Address - Phone:423-337-2829
Practice Address - Fax:423-337-5574
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3525183500000X
FL26164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist