Provider Demographics
NPI:1114225612
Name:SIMONS, JACK D (LPC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:SIMONS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S MERAMEC AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3511
Mailing Address - Country:US
Mailing Address - Phone:636-236-8849
Mailing Address - Fax:
Practice Address - Street 1:225 S MERAMEC AVE STE 211
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:636-236-8849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-12181101Y00000X
MO2010006422101YP2500X
WI4430-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor