Provider Demographics
NPI:1588648059
Name:TAYLOR, JERRAL DEWAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRAL
Middle Name:DEWAYNE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:DEWAYNE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2900 E 29TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2623
Mailing Address - Country:US
Mailing Address - Phone:979-776-8440
Mailing Address - Fax:
Practice Address - Street 1:2900 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2622
Practice Address - Country:US
Practice Address - Phone:979-776-8440
Practice Address - Fax:877-601-5854
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3652103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000B40A2Medicaid
TX00B40AMedicare ID - Type Unspecified
TXP000B40A2Medicaid