Provider Demographics
NPI:1396918694
Name:HUGHES, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:HUGHES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GRAYSON DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-8910
Mailing Address - Country:US
Mailing Address - Phone:864-901-6554
Mailing Address - Fax:
Practice Address - Street 1:379 PINEHAVEN ST. EXT.
Practice Address - Street 2:SUITE 120
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360
Practice Address - Country:US
Practice Address - Phone:864-832-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2731172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker