Provider Demographics
NPI:1437422813
Name:OLIVE, JERRY WAYNE (LPC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:OLIVE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SOVEREIGN CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4441
Mailing Address - Country:US
Mailing Address - Phone:636-448-5184
Mailing Address - Fax:
Practice Address - Street 1:301 SOVEREIGN CT
Practice Address - Street 2:SUITE 105
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4441
Practice Address - Country:US
Practice Address - Phone:636-448-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009012865101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health