Provider Demographics
NPI:1528229598
Name:EDMONDSON, JERRY MITCHELL (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MITCHELL
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2849 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2626
Mailing Address - Country:US
Mailing Address - Phone:314-910-3099
Mailing Address - Fax:
Practice Address - Street 1:2849 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2626
Practice Address - Country:US
Practice Address - Phone:314-910-3099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-22
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008012530101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008012530OtherLICENSED NUMBER FOR STATE OF MISSOURI LICENSED PROFESSIONAL COUNSELOR