Provider Demographics
NPI:1164912283
Name:PRICE, JERRY L JR (MBA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:PRICE
Suffix:JR
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 N KENMORE AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2727
Mailing Address - Country:US
Mailing Address - Phone:312-898-2831
Mailing Address - Fax:
Practice Address - Street 1:6412 27TH ST # AT
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2755
Practice Address - Country:US
Practice Address - Phone:312-898-2831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst