MEDICARE: JERY A WALWORTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	7501016847	MI

General Provider Information

NPI Number	:	1154252724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERY A WALWORTH

Provider Business Mailing Address
First Line	:	4498 OLD CARRIAGE RD
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48507-5622
Country	:	US
Telephone Number	:	810-397-7438
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 E REID RD STE 210
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-2416
Country	:	US
Telephone Number	:	810-397-7438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2026
Last Update Date	:	05/25/2026

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