Healthcare Provider Details

I. General information

NPI: 1952728404
Provider Name (Legal Business Name): JERELLE L PERRY SR. MASSAGE THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2014
Last Update Date: 03/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 EUNICE LN
WENDELL NC
27591-7068
US

IV. Provider business mailing address

2916 EUNICE LN
WENDELL NC
27591-7068
US

V. Phone/Fax

Practice location:
  • Phone: 919-904-2714
  • Fax:
Mailing address:
  • Phone: 919-904-2714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11330
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: