Provider Demographics
NPI:1093111999
Name:REDD, JERRY (PHD, CMHC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:REDD
Suffix:
Gender:M
Credentials:PHD, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 W STATE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4109
Mailing Address - Country:US
Mailing Address - Phone:801-785-8885
Mailing Address - Fax:
Practice Address - Street 1:1364 W STATE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4109
Practice Address - Country:US
Practice Address - Phone:801-785-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT55044786004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health