Provider Demographics
NPI:1376833673
Name:JERRY, KRYSTAL LYNN (MD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
Last Name:JERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W JOHN CARPENTER FWY STE 420
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2014
Mailing Address - Country:US
Mailing Address - Phone:972-957-9300
Mailing Address - Fax:
Practice Address - Street 1:490 IH 10 N STE 100
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1819
Practice Address - Country:US
Practice Address - Phone:409-212-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9207208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2150570Medicaid