Provider Demographics
NPI:1023158870
Name:HORNER, JERRY W II (HEALTH SERVICES TECH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:HORNER
Suffix:II
Gender:M
Credentials:HEALTH SERVICES TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404C UTAH DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-765-7524
Mailing Address - Fax:707-765-7495
Practice Address - Street 1:599 TOMALE RD
Practice Address - Street 2:BLDG 125 ROOM 106
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-765-7524
Practice Address - Fax:707-765-7495
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other