1366503740 NPI number — JERRY C CLERC MED LPC

Table of content: JERRY C CLERC MED LPC (NPI 1366503740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366503740 NPI number — JERRY C CLERC MED LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLERC
Provider First Name:
JERRY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MED LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLERC
Provider Other First Name:
JEROME
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MED LPC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366503740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3631 TAMM
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-863-3588
Provider Business Mailing Address Fax Number:
314-863-0074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 SO MERAMEC
Provider Second Line Business Practice Location Address:
ST 506
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-863-3588
Provider Business Practice Location Address Fax Number:
314-863-0074
Provider Enumeration Date:
12/12/2006

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: 101YM0800X , with the licence number:  000683 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ANTHEM 1111 . This is a "BCBS ANTHEM NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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