Provider Demographics
NPI:1437294295
Name:TRAYLOR, JERRY THOMAS
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:THOMAS
Last Name:TRAYLOR
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 1:1401 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8096
Mailing Address - Country:US
Mailing Address - Phone:417-239-4368
Mailing Address - Fax:334-513-1784
Practice Address - Street 1:1401 S 13TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8096
Practice Address - Country:US
Practice Address - Phone:417-239-4368
Practice Address - Fax:334-513-1784
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator