Provider Demographics
NPI:1417728882
Name:MISSOURI, MICHAEL JERRY JR
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JERRY
Last Name:MISSOURI
Suffix:JR
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 1:816 SOUTHERN AVE SE APT 301
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-3497
Mailing Address - Country:US
Mailing Address - Phone:202-802-3962
Mailing Address - Fax:
Practice Address - Street 1:431 54TH ST SE APT A1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-6573
Practice Address - Country:US
Practice Address - Phone:202-200-6558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant