Provider Demographics
NPI:1174966972
Name:THORNE, JERRY LEE
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:THORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 NE BABBIT ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-1424
Mailing Address - Country:US
Mailing Address - Phone:580-704-0611
Mailing Address - Fax:
Practice Address - Street 1:122 NE BABBIT ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1424
Practice Address - Country:US
Practice Address - Phone:580-704-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor