Provider Demographics
NPI:1023139441
Name:MALONE, JEROME C (PT)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:C
Last Name:MALONE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0791
Mailing Address - Country:US
Mailing Address - Phone:517-783-6670
Mailing Address - Fax:517-783-5310
Practice Address - Street 1:206 PAGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2418
Practice Address - Country:US
Practice Address - Phone:517-783-6670
Practice Address - Fax:517-783-5310
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM002302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C857040OtherBCBS
MI0M94500002Medicare ID - Type UnspecifiedMEDICARE