Provider Demographics
NPI:1275535437
Name:FREEMAN, JERRIE D (PA)
Entity Type:Individual
Prefix:
First Name:JERRIE
Middle Name:D
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 YUMA TRL
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5117
Mailing Address - Country:US
Mailing Address - Phone:706-650-9878
Mailing Address - Fax:
Practice Address - Street 1:3614 J DEWEY GRAY CIR STE D
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6512
Practice Address - Country:US
Practice Address - Phone:706-868-7380
Practice Address - Fax:706-868-7223
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCFSCMedicare ID - Type Unspecified