Provider Demographics
NPI:1093235327
Name:WOLFE, JERRY BALCOM (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:BALCOM
Last Name:WOLFE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E ARMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101
Mailing Address - Country:US
Mailing Address - Phone:630-530-2510
Mailing Address - Fax:630-530-2569
Practice Address - Street 1:33 E ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-4853
Practice Address - Country:US
Practice Address - Phone:630-530-2510
Practice Address - Fax:630-530-2569
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002142103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty