Provider Demographics
NPI:1205831575
Name:GILLON, JERRY FRANCIS (PT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:FRANCIS
Last Name:GILLON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 BOYSON RD NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-7363
Mailing Address - Country:US
Mailing Address - Phone:319-294-4989
Mailing Address - Fax:319-294-2419
Practice Address - Street 1:576 BOYSON RD NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-7363
Practice Address - Country:US
Practice Address - Phone:319-294-4989
Practice Address - Fax:319-294-2419
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0241117Medicaid
IA11467OtherWELLMARK
IA650019783OtherRAILROAD MEDICARE
IA0241117Medicaid