Provider Demographics
NPI:1740076389
Name:WHITE, JERRY LEE III
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:WHITE
Suffix:III
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 MCMILLAN AVE STE 164
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6768
Mailing Address - Country:US
Mailing Address - Phone:805-439-4890
Mailing Address - Fax:
Practice Address - Street 1:2975 MCMILLAN AVE STE 164
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6768
Practice Address - Country:US
Practice Address - Phone:805-439-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist