Provider Demographics
NPI:1598926644
Name:BAMBURG, JERALD W JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:W
Last Name:BAMBURG
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N BEND DR
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4677
Mailing Address - Country:US
Mailing Address - Phone:318-442-4498
Mailing Address - Fax:
Practice Address - Street 1:106 N BEND DR
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4677
Practice Address - Country:US
Practice Address - Phone:318-442-4498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA951103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent