Provider Demographics
NPI:1407849037
Name:BARRETT, JERRY OWEN (MD)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:OWEN
Last Name:BARRETT
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 235
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:TN
Mailing Address - Zip Code:38449-0235
Mailing Address - Country:US
Mailing Address - Phone:931-427-3565
Mailing Address - Fax:931-427-8111
Practice Address - Street 1:26303 SAVINGS CENTER DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:TN
Practice Address - Zip Code:38449-3273
Practice Address - Country:US
Practice Address - Phone:931-427-3565
Practice Address - Fax:931-427-8111
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD011762208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3170577Medicaid
AL000810174Medicaid
TN000055623OtherBLUE CROSS
B03413Medicare UPIN
3170577Medicare ID - Type Unspecified