Provider Demographics
NPI:1821599598
Name:PERRY, AARONJACK RUSSELL III
Entity Type:Individual
Prefix:
First Name:AARONJACK
Middle Name:RUSSELL
Last Name:PERRY
Suffix:III
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 1:1545 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-1411
Mailing Address - Country:US
Mailing Address - Phone:559-281-9575
Mailing Address - Fax:
Practice Address - Street 1:1545 5TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-1411
Practice Address - Country:US
Practice Address - Phone:559-281-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
83109OtherCALIFORNIA COMMUNITY NETWORK