Provider Demographics
NPI:1336347087
Name:HOULE, JEROME L IV (PA-C)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:HOULE
Suffix:IV
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2101
Practice Address - Country:US
Practice Address - Phone:203-694-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1914363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004026712Medicaid
1336347087OtherNPI
CTD40001756 - C00814Medicare PIN