Provider Demographics
NPI:1295837474
Name:HART, JERRY LEE (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:HART
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 UNIVERSITY BLVD E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2086
Mailing Address - Country:US
Mailing Address - Phone:205-556-7145
Mailing Address - Fax:205-553-9127
Practice Address - Street 1:701 UNIVERSITY BLVD E
Practice Address - Street 2:SUITE 204
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2086
Practice Address - Country:US
Practice Address - Phone:205-556-7145
Practice Address - Fax:205-553-9127
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL306103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL70775Medicare ID - Type Unspecified
R35732Medicare UPIN