Provider Demographics
NPI:1861759656
Name:BRAND, JERRY LEE (LMT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:BRAND
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 RIDENOUR RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-2067
Mailing Address - Country:US
Mailing Address - Phone:614-207-7578
Mailing Address - Fax:
Practice Address - Street 1:618 RIDENOUR RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-2067
Practice Address - Country:US
Practice Address - Phone:614-207-7578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33-020021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist