Provider Demographics
NPI:1821327685
Name:TILLEY, JERRY
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:TILLEY
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 1:8005 N POINT BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3267
Mailing Address - Country:US
Mailing Address - Phone:336-759-7207
Mailing Address - Fax:336-759-7209
Practice Address - Street 1:8005 N POINT BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3267
Practice Address - Country:US
Practice Address - Phone:336-759-7207
Practice Address - Fax:336-759-7209
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3958171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator