Provider Demographics
NPI:1316151079
Name:ERSLAND, JEROME JAY (DPH PHD)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JAY
Last Name:ERSLAND
Suffix:
Gender:M
Credentials:DPH PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 NORTH 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018
Mailing Address - Country:US
Mailing Address - Phone:405-224-0724
Mailing Address - Fax:
Practice Address - Street 1:1300 NORTH 29TH STREET
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018
Practice Address - Country:US
Practice Address - Phone:405-224-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8996183500000X
TX21539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21539OtherSTATE BD OF PHARMACY
OK8996OtherSTATE BD OF PHARMACY