Healthcare Provider Details

I. General information

NPI: 1154252724
Provider Name (Legal Business Name): JERY A WALWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E REID RD STE 210
GRAND BLANC MI
48439-2416
US

IV. Provider business mailing address

4498 OLD CARRIAGE RD
FLINT MI
48507-5622
US

V. Phone/Fax

Practice location:
  • Phone: 810-397-7438
  • Fax:
Mailing address:
  • Phone: 810-397-7438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501016847
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: