Provider Demographics
NPI:1558514919
Name:THOMASON, JERRY WAYNE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:THOMASON
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 ZEAGLER DR.
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177
Mailing Address - Country:US
Mailing Address - Phone:386-326-8500
Mailing Address - Fax:386-325-0134
Practice Address - Street 1:611 ZEAGLER DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3810
Practice Address - Country:US
Practice Address - Phone:386-326-8500
Practice Address - Fax:386-325-0134
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6521235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist