Provider Demographics
NPI:1205258092
Name:MARSH, JERRY L (CSFA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:MARSH
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 EMMA GRACE LN
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-7657
Mailing Address - Country:US
Mailing Address - Phone:704-705-0973
Mailing Address - Fax:925-401-2990
Practice Address - Street 1:2404 EMMA GRACE LN
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-7657
Practice Address - Country:US
Practice Address - Phone:704-705-0973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC146613246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246ZC0007XMedicaid