Provider Demographics
NPI:1497084677
Name:POOLE, JERALD J (IDC)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:J
Last Name:POOLE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS RAMAGE
Mailing Address - Street 2:DDG 61
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09586-1279
Mailing Address - Country:US
Mailing Address - Phone:757-445-6208
Mailing Address - Fax:
Practice Address - Street 1:USS RAMAGE
Practice Address - Street 2:DDG 61
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09586-1279
Practice Address - Country:US
Practice Address - Phone:757-445-6208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1710L1002X1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman