Provider Demographics
NPI:1659925725
Name:REED, JERRY KENNETH
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:KENNETH
Last Name:REED
Suffix:
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 1:1415 BIG STONE GAP RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-2003
Mailing Address - Country:US
Mailing Address - Phone:469-297-0430
Mailing Address - Fax:469-776-5200
Practice Address - Street 1:1415 BIG STONE GAP RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-2003
Practice Address - Country:US
Practice Address - Phone:469-297-0430
Practice Address - Fax:469-776-5200
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147168376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106818OtherTEXAS STATE ASSISTED LIVING VENDOR/FACILITY ID