Provider Demographics
NPI:1578273488
Name:EVERSOLE, JERRY WAYNE (LPN)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:EVERSOLE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CROSS AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 E LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IN
Practice Address - Zip Code:47243-9618
Practice Address - Country:US
Practice Address - Phone:812-273-4640
Practice Address - Fax:812-273-2925
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27065312A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse