Provider Demographics
NPI:1215638101
Name:FERRELL, JESSE (IDMT)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:FERRELL
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W D.L. INGRAM AVE
Mailing Address - Street 2:BLDG 1408
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:575-784-8512
Mailing Address - Fax:
Practice Address - Street 1:224 W DL. INGRAM AVE
Practice Address - Street 2:BLDG 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-784-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians