Provider Demographics
NPI:1942195862
Name:EARLEY, JERRY LEE
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:EARLEY
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 1:226 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MINGO JUNCTION
Mailing Address - State:OH
Mailing Address - Zip Code:43938-1352
Mailing Address - Country:US
Mailing Address - Phone:704-470-7285
Mailing Address - Fax:
Practice Address - Street 1:226 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MINGO JUNCTION
Practice Address - State:OH
Practice Address - Zip Code:43938-1352
Practice Address - Country:US
Practice Address - Phone:704-470-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV125553494Medicaid
WV1821206228Medicaid