Provider Demographics
NPI:1518580414
Name:LEMELLE, JERRY TYRONE (CTRS)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:TYRONE
Last Name:LEMELLE
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:TYRONE
Other - Last Name:LEMELLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CTRS
Mailing Address - Street 1:7400 MERTON MINTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:877-469-5300
Mailing Address - Fax:
Practice Address - Street 1:4455 HORIZON HILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2258
Practice Address - Country:US
Practice Address - Phone:337-794-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
26454225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist