Provider Demographics
NPI:1952359523
Name:JESSEPH, JERRY MICHAEL
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:JESSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:MICHAEL
Other - Last Name:JESSEPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47458-0096
Mailing Address - Country:US
Mailing Address - Phone:812-824-8787
Mailing Address - Fax:812-824-8787
Practice Address - Street 1:901 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2205
Practice Address - Country:US
Practice Address - Phone:812-332-7277
Practice Address - Fax:812-332-0405
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030317A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN544730Medicare ID - Type Unspecified
INB29199Medicare UPIN