Provider Demographics
NPI:1619044138
Name:BARRETT, JERALDINE (LCSW)
Entity Type:Individual
Prefix:
First Name:JERALDINE
Middle Name:
Last Name:BARRETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JERRI
Other - Middle Name:
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-0956
Mailing Address - Country:US
Mailing Address - Phone:307-358-3056
Mailing Address - Fax:
Practice Address - Street 1:261 BROWNFIELD RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2570
Practice Address - Country:US
Practice Address - Phone:307-358-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-290101YA0400X
WYLCSW-4131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW21552Medicare PIN
WYW20070Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER