Provider Demographics
NPI:1508111774
Name:MOTT, JERRY MARK (MS)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MARK
Last Name:MOTT
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 SHILOH CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-3069
Mailing Address - Country:US
Mailing Address - Phone:251-380-0215
Mailing Address - Fax:
Practice Address - Street 1:3510 MONTLIMAR PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1746
Practice Address - Country:US
Practice Address - Phone:251-380-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1557101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1557OtherLICENSED PROFESSIONAL COUNSELOR