Provider Demographics
NPI:1447846217
Name:JERYC, WALTER
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:JERYC
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 1:5840 INTERFACE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9176
Mailing Address - Country:US
Mailing Address - Phone:734-627-8001
Mailing Address - Fax:
Practice Address - Street 1:5840 INTERFACE DR STE 400
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9176
Practice Address - Country:US
Practice Address - Phone:734-627-8001
Practice Address - Fax:734-929-2588
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist