Provider Demographics
NPI:1669414629
Name:PRESLEY, JERRY EDWARD (PT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:EDWARD
Last Name:PRESLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 PARR AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2078
Mailing Address - Country:US
Mailing Address - Phone:731-285-6600
Mailing Address - Fax:731-285-8005
Practice Address - Street 1:2265 PARR AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2078
Practice Address - Country:US
Practice Address - Phone:731-285-6600
Practice Address - Fax:731-285-8005
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000005425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPT0000005425OtherPHYSICAL THERAPY LICENSE
TN3687549Medicaid
TN3687549Medicaid