Provider Demographics
NPI:1427818301
Name:JERRELL, MICAH LUKE (DPM)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:LUKE
Last Name:JERRELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9729 COLONYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75072-4957
Mailing Address - Country:US
Mailing Address - Phone:469-422-3654
Mailing Address - Fax:
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2692
Practice Address - Country:US
Practice Address - Phone:716-862-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program