Healthcare Provider Details

I. General information

NPI: 1043044126
Provider Name (Legal Business Name): JERRY L DYSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 RUCKLE ST
INDIANAPOLIS IN
46205-3839
US

IV. Provider business mailing address

3241 RUCKLE ST
INDIANAPOLIS IN
46205-3839
US

V. Phone/Fax

Practice location:
  • Phone: 317-205-5206
  • Fax:
Mailing address:
  • Phone: 317-975-9655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: