Provider Demographics
NPI:1104103829
Name:LLOYD, JERRY LEE JR (AT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:LLOYD
Suffix:JR
Gender:M
Credentials:AT
Other - Prefix:MR
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:LLOYD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AT
Mailing Address - Street 1:4138 N 47TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4313
Mailing Address - Country:US
Mailing Address - Phone:602-952-1508
Mailing Address - Fax:
Practice Address - Street 1:444 W OSBORN RD
Practice Address - Street 2:SUITE 303
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3814
Practice Address - Country:US
Practice Address - Phone:602-279-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ02102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer