Provider Demographics
NPI:1497865869
Name:CUNNINGHAM, JERA NELSON (PHD, LCP)
Entity Type:Individual
Prefix:DR
First Name:JERA NELSON
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PHD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9097 ATLEE STATION RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2525
Mailing Address - Country:US
Mailing Address - Phone:804-730-0432
Mailing Address - Fax:804-730-2829
Practice Address - Street 1:9097 ATLEE STATION RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2525
Practice Address - Country:US
Practice Address - Phone:804-730-0432
Practice Address - Fax:804-730-2829
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA173266OtherANTHEM PROVIDER NUMBER