Provider Demographics
NPI:1255655114
Name:MARKWORTH, JERI L
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:L
Last Name:MARKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7539 E GEARY DOME RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:82636-9692
Mailing Address - Country:US
Mailing Address - Phone:307-797-0827
Mailing Address - Fax:
Practice Address - Street 1:7539 E GEARY DOME RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WY
Practice Address - Zip Code:82636-9692
Practice Address - Country:US
Practice Address - Phone:307-797-0827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY127038900Medicaid