Provider Demographics
NPI:1548059249
Name:THOMAS, JERRY TYWONE SR
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:TYWONE
Last Name:THOMAS
Suffix:SR
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 1:235 HARRY S TRUMAN DR APT 13
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2033
Mailing Address - Country:US
Mailing Address - Phone:202-718-2298
Mailing Address - Fax:
Practice Address - Street 1:1717 E CAPITOL ST SE APT 241
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-1787
Practice Address - Country:US
Practice Address - Phone:202-718-2298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant