Provider Demographics
NPI:1902632706
Name:JERRELL, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:JERRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 CUMBERLAND AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1343
Mailing Address - Country:US
Mailing Address - Phone:812-483-5533
Mailing Address - Fax:812-483-5533
Practice Address - Street 1:1305 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1310
Practice Address - Country:US
Practice Address - Phone:812-483-5533
Practice Address - Fax:812-483-5533
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator