Provider Demographics
NPI:1417194291
Name:CONSTANCE, JERRY HAROLD (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:HAROLD
Last Name:CONSTANCE
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 1:111 CALDWELL DR
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7740
Mailing Address - Country:US
Mailing Address - Phone:865-414-3862
Mailing Address - Fax:
Practice Address - Street 1:5580 ROANE STATE HWY
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854-4332
Practice Address - Country:US
Practice Address - Phone:865-354-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical