Provider Demographics
NPI:1558451948
Name:FORSYTH, JERALD DELBERT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:DELBERT
Last Name:FORSYTH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 W WILLOW LAKES CV
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1562
Mailing Address - Country:US
Mailing Address - Phone:417-844-8423
Mailing Address - Fax:
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9357
Practice Address - Country:US
Practice Address - Phone:417-753-9404
Practice Address - Fax:417-753-9137
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical