Healthcare Provider Details

I. General information

NPI: 1083738140
Provider Name (Legal Business Name): MR. JERRY PARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 N PERRY CREEK RD
MIO MI
48647-9718
US

IV. Provider business mailing address

1364 N PERRY CREEK RD
MIO MI
48647-9718
US

V. Phone/Fax

Practice location:
  • Phone: 989-390-3718
  • Fax:
Mailing address:
  • Phone: 989-390-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: