=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356152466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY CALHOUN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2025
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 283 HINKLE ST
-----------------------------------------------------
City | TERRA ALTA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26764-6291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-321-4667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 245
-----------------------------------------------------
City | TERRA ALTA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26764-0245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------