Provider Demographics
NPI:1598564544
Name:ORR, JERRY JAMES (CCSS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:JAMES
Last Name:ORR
Suffix:
Gender:
Credentials:CCSS
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:JAMES
Other - Last Name:ORR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1007 E GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5439
Mailing Address - Country:US
Mailing Address - Phone:505-870-9812
Mailing Address - Fax:
Practice Address - Street 1:1808 E AZTEC AVE STE 6
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4946
Practice Address - Country:US
Practice Address - Phone:505-870-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NM172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker