Provider Demographics
NPI:1598462897
Name:EWERTZ, JERI LYNN (COA)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:LYNN
Last Name:EWERTZ
Suffix:
Gender:F
Credentials:COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 N ESTATE RD
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:KS
Mailing Address - Zip Code:67120-9009
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:316-239-2747
Practice Address - Street 1:949 S GLENDALE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3210
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:316-239-2747
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS149204156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant