1831386747 NPI number — MR. JERRY HAMILTON LCSW

Table of content: MR. JERRY HAMILTON LCSW (NPI 1831386747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831386747 NPI number — MR. JERRY HAMILTON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMILTON
Provider First Name:
JERRY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831386747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7165 GETWELL DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38109-1722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-345-0636
Provider Business Mailing Address Fax Number:
662-772-3259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7165 GETWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38672-9618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-349-2818
Provider Business Practice Location Address Fax Number:
662-342-3406
Provider Enumeration Date:
09/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  3165 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 1502 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3699016 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 568759-000 . This is a "MAGELLAN HEALTH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 11549639 . This is a "CAQH AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4114450 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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