MEDICARE: DR. LORRAINE RACHEL JERUD DR

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	1223P0300X	Periodontics	13368	NJ

General Provider Information

NPI Number	:	1366524357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORRAINE RACHEL JERUD DR

Provider Business Mailing Address
First Line	:	114 S NASHVILLE AVE
Second Line	:
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406-2943
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 S NASHVILLE AVE
Second Line	:
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406-2943
Country	:	US
Telephone Number	:	856-589-5363
Fax Number	:

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/08/2007

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