Provider Demographics
NPI:1013552926
Name:BARNES, JERROLD ANTHONY
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:ANTHONY
Last Name:BARNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JERROLD
Other - Middle Name:ANTHONY
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:66 QUINBY AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-3112
Mailing Address - Country:US
Mailing Address - Phone:914-629-4554
Mailing Address - Fax:
Practice Address - Street 1:66 QUINBY AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10606-3112
Practice Address - Country:US
Practice Address - Phone:914-629-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136760164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY136760Medicaid