Provider Demographics
NPI:1891992657
Name:BLAKELY, JERRY W II (PT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:BLAKELY
Suffix:II
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2200 IRONWOOD PL
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2610
Mailing Address - Country:US
Mailing Address - Phone:208-667-6486
Mailing Address - Fax:
Practice Address - Street 1:2200 IRONWOOD PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2610
Practice Address - Country:US
Practice Address - Phone:208-667-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic