Provider Demographics
NPI:1013144286
Name:GARNER, JERRY K (LAC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:K
Last Name:GARNER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6147
Mailing Address - Country:US
Mailing Address - Phone:208-535-0006
Mailing Address - Fax:208-535-0007
Practice Address - Street 1:1210 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6147
Practice Address - Country:US
Practice Address - Phone:208-535-0006
Practice Address - Fax:208-535-0007
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-105171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist