Provider Demographics
NPI:1023125143
Name:FORINASH, JERRY BLAINE JR (MPT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:BLAINE
Last Name:FORINASH
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WEST VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4460
Mailing Address - Country:US
Mailing Address - Phone:304-669-1971
Mailing Address - Fax:
Practice Address - Street 1:611 WEST VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:NUTTER FORT
Practice Address - State:WV
Practice Address - Zip Code:26301-4460
Practice Address - Country:US
Practice Address - Phone:304-669-1971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006744Medicaid
WV3810006744Medicaid