Provider Demographics
NPI:1518767516
Name:RENESIS, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:RENESIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 WOODLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-4641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2111 WOODLAND RD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-4641
Practice Address - Country:US
Practice Address - Phone:757-285-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program