Healthcare Provider Details

I. General information

NPI: 1396727400
Provider Name (Legal Business Name): JEFFREY IRA GERRY MDPHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD STE 204
PORTLAND OR
97225-6625
US

IV. Provider business mailing address

PO BOX 821350
VANCOUVER WA
98682-0030
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-7463
  • Fax: 503-297-8835
Mailing address:
  • Phone: 503-283-5220
  • Fax: 503-283-9527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD16613
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: