Provider Demographics
NPI:1215549373
Name:ANDERSON, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 OLD LOGAN RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3367
Mailing Address - Country:US
Mailing Address - Phone:304-687-7783
Mailing Address - Fax:
Practice Address - Street 1:3061 OLD LOGAN RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3367
Practice Address - Country:US
Practice Address - Phone:304-687-7783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant