Provider Demographics
NPI:1407473093
Name:DAUGHERTY, JERRA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JERRA
Middle Name:L
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 KINGS POINT AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-2975
Mailing Address - Country:US
Mailing Address - Phone:785-223-7714
Mailing Address - Fax:
Practice Address - Street 1:84 KINGS POINT AVE
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-2975
Practice Address - Country:US
Practice Address - Phone:785-223-7714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040114601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical