Provider Demographics
NPI:1457323560
Name:DAVIS, JERRY (LMHC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 N MARR RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-6660
Mailing Address - Country:US
Mailing Address - Phone:812-314-3400
Mailing Address - Fax:812-378-8367
Practice Address - Street 1:1530 COMMERCE PARK WEST DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240
Practice Address - Country:US
Practice Address - Phone:812-663-7057
Practice Address - Fax:812-378-8367
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001542A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000321018OtherANTHEM PIN