Provider Demographics
NPI:1225119811
Name:STANLEY, JERRI LYNN
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:LYNN
Last Name:STANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47375-0487
Mailing Address - Country:US
Mailing Address - Phone:765-983-8000
Mailing Address - Fax:765-983-8609
Practice Address - Street 1:2545 SW M ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-969-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162275101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)