1912908963 NPI number — DR. JERRELL LEE DRIVER PHD

Table of content: DR. JERRELL LEE DRIVER PHD (NPI 1912908963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912908963 NPI number — DR. JERRELL LEE DRIVER PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRIVER
Provider First Name:
JERRELL
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1912908963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
POST OFFICE BOX 1642
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63702-1642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-204-7771
Provider Business Mailing Address Fax Number:
573-204-7771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2387 W JACKSON BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63755-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-204-7771
Provider Business Practice Location Address Fax Number:
573-204-7771
Provider Enumeration Date:
08/02/2005

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: 103TC0700X , with the licence number:  PY 00099 , 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: PY00099 . This is a "MO-LICENSE PSYCHOLOGIST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 493204309 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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