Provider Demographics
NPI:1376667709
Name:SIMMONS, JERRY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 PITTSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-4103
Mailing Address - Country:US
Mailing Address - Phone:570-961-5419
Mailing Address - Fax:570-961-0962
Practice Address - Street 1:722 PITTSTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-4103
Practice Address - Country:US
Practice Address - Phone:570-961-5419
Practice Address - Fax:570-961-0962
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001898L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006194710002Medicaid
PAT28485Medicare UPIN
PA0006194710002Medicaid