1346383106 NPI number — MR. JERRY WILLIE PICKENS JERRY PICKENS

Table of content: MR. JERRY WILLIE PICKENS JERRY PICKENS (NPI 1346383106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346383106 NPI number — MR. JERRY WILLIE PICKENS JERRY PICKENS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKENS
Provider First Name:
JERRY
Provider Middle Name:
WILLIE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
JERRY PICKENS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PICKENS
Provider Other First Name:
JERRY
Provider Other Middle Name:
WILLIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
JERRY PICKENS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1346383106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2520 PEACHTREE RD NW APT 116
Provider Second Line Business Mailing Address:
116
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305-3617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-846-8100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 PEACHTREE RD NW APT 116
Provider Second Line Business Practice Location Address:
116
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30305-3617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-846-8100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  204 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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