Provider Demographics
NPI:1194861922
Name:ANDERSON, JERRY LEE (PT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 SANDWEDGE CT
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-8833
Mailing Address - Country:US
Mailing Address - Phone:316-218-0919
Mailing Address - Fax:
Practice Address - Street 1:1151 N ROCK RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1262
Practice Address - Country:US
Practice Address - Phone:316-634-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist