Provider Demographics
NPI:1215207113
Name:JOERN, JERRY EARL (PA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:EARL
Last Name:JOERN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14613 FOSSIL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1838
Mailing Address - Country:US
Mailing Address - Phone:405-752-0672
Mailing Address - Fax:
Practice Address - Street 1:15151 E. HWY 39
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:OK
Practice Address - Zip Code:73051
Practice Address - Country:US
Practice Address - Phone:405-527-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant