Provider Demographics
NPI:1992141733
Name:JAY, DERRICK (RRT)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:JAY
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE SPRING
Mailing Address - State:SC
Mailing Address - Zip Code:29129-9555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 DAVIS RD
Practice Address - Street 2:
Practice Address - City:RIDGE SPRING
Practice Address - State:SC
Practice Address - Zip Code:29129-9555
Practice Address - Country:US
Practice Address - Phone:803-685-7508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA-5442227900000X
SCRCP4458227900000X
GA8468227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA-5442OtherRESPIRATORY CARE PRACTITIONER
SCRCP4458OtherRESPIRATORY CARE PRACTITIONER
GA8468OtherRESPIRATORY CARE PRACTITIONER