Provider Demographics
NPI:1245799378
Name:CROCKRELL, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:CROCKRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 N ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2604
Mailing Address - Country:US
Mailing Address - Phone:708-513-3494
Mailing Address - Fax:
Practice Address - Street 1:411 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1065
Practice Address - Country:US
Practice Address - Phone:815-432-5241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)