Healthcare Provider Details

I. General information

NPI: 1902727084
Provider Name (Legal Business Name): JERRY RUSSELL MOBLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8316 COUNTY ROAD 71
PAULDING OH
45879-9102
US

IV. Provider business mailing address

8316 COUNTY ROAD 71
PAULDING OH
45879-9102
US

V. Phone/Fax

Practice location:
  • Phone: 419-796-1369
  • Fax:
Mailing address:
  • Phone: 419-796-1369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberRU469140
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: