Provider Demographics
NPI:1225158447
Name:GERGECEFF, JON R (LCSW)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:GERGECEFF
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8711 WATSON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5100
Mailing Address - Country:US
Mailing Address - Phone:314-961-9871
Mailing Address - Fax:314-961-9877
Practice Address - Street 1:8711 WATSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5100
Practice Address - Country:US
Practice Address - Phone:314-961-9871
Practice Address - Fax:314-961-9877
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0031331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO775151485OtherMEDICARE PTAN