Provider Demographics
NPI:1053955179
Name:HA, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:HA
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 1:841 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-2710
Mailing Address - Country:US
Mailing Address - Phone:704-252-1604
Mailing Address - Fax:
Practice Address - Street 1:650 S TRYON ST STE 440
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-3271
Practice Address - Country:US
Practice Address - Phone:704-626-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program