Provider Demographics
NPI:1275090755
Name:SLAWSON, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SLAWSON
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 1:412 W. CHAMPLAIN AVE.
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:757-912-4586
Mailing Address - Fax:
Practice Address - Street 1:412 W CHAMPLAIN AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-2014
Practice Address - Country:US
Practice Address - Phone:757-912-4586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer