Provider Demographics
NPI:1932624244
Name:JERRY, RANDALL W (DPT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:W
Last Name:JERRY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10730
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-0028
Mailing Address - Country:US
Mailing Address - Phone:870-875-5124
Mailing Address - Fax:870-875-5198
Practice Address - Street 1:2700 VINE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6700
Practice Address - Country:US
Practice Address - Phone:870-875-5124
Practice Address - Fax:870-875-5198
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist