Provider Demographics
NPI:1568589349
Name:MOTE, JERRY THOMAS (LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:THOMAS
Last Name:MOTE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 WELLWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-3647
Mailing Address - Country:US
Mailing Address - Phone:423-364-5853
Mailing Address - Fax:
Practice Address - Street 1:6250 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-3857
Practice Address - Country:US
Practice Address - Phone:423-364-5853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004699101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional