Provider Demographics
NPI:1316182769
Name:COUCH, JERRY LEE JR
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:COUCH
Suffix:JR
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 1:4832 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-4845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 W WALNUT PKWY
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-5030
Practice Address - Country:US
Practice Address - Phone:310-868-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health