Provider Demographics
NPI:1952361669
Name:HALL, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 SW H K DODGEN LOOP BLDG 300
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1814
Practice Address - Country:US
Practice Address - Phone:254-724-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ20462080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1205320-05Medicaid
TX8S6323OtherBLUE SHIELD
TX1205320-06OtherCSHCN
TXF91834Medicare UPIN
TX1205320-05Medicaid