Provider Demographics
NPI:1023284353
Name:JERRY, JASON MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MATTHEW
Last Name:JERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8708
Mailing Address - Country:US
Mailing Address - Phone:910-715-3376
Mailing Address - Fax:
Practice Address - Street 1:35 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8708
Practice Address - Country:US
Practice Address - Phone:910-715-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME867592084A0401X
NC2016-025702084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3065454Medicaid
NC1023284353Medicaid