Provider Demographics
NPI:1821145947
Name:STANLEY, JERRY LYNN (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LYNN
Last Name:STANLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-3208
Mailing Address - Country:US
Mailing Address - Phone:406-234-2634
Mailing Address - Fax:
Practice Address - Street 1:103 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-3208
Practice Address - Country:US
Practice Address - Phone:406-234-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT389111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTT89306Medicare UPIN
MT000004070Medicare PIN