Provider Demographics
NPI:1306909551
Name:SULLIVAN, JERRY L JR (ATC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1657
Mailing Address - Country:US
Mailing Address - Phone:217-824-2863
Mailing Address - Fax:
Practice Address - Street 1:3631 S. SIXTH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703
Practice Address - Country:US
Practice Address - Phone:217-341-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer