Provider Demographics
NPI:1447702154
Name:MALLORY, JERRY C JR
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:C
Last Name:MALLORY
Suffix:JR
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 1:4018 BAYARD
Mailing Address - Street 2:4018 BAYARD
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:216-533-0094
Mailing Address - Fax:
Practice Address - Street 1:4018 BAYARD 44121
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:44121
Practice Address - Country:US
Practice Address - Phone:216-533-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider