Provider Demographics
NPI:1508664731
Name:THOMAS, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 PRIVATE ROAD 4777
Mailing Address - Street 2:
Mailing Address - City:PEDRO
Mailing Address - State:OH
Mailing Address - Zip Code:45659-9047
Mailing Address - Country:US
Mailing Address - Phone:740-646-4710
Mailing Address - Fax:
Practice Address - Street 1:285 PRIVATE ROAD 4777
Practice Address - Street 2:
Practice Address - City:PEDRO
Practice Address - State:OH
Practice Address - Zip Code:45659-9047
Practice Address - Country:US
Practice Address - Phone:740-646-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services