Provider Demographics
NPI:1679592661
Name:EVANS, JEROME C (LCSW)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:C
Last Name:EVANS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 DIXIE LN S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3914
Mailing Address - Country:US
Mailing Address - Phone:727-823-5555
Mailing Address - Fax:
Practice Address - Street 1:1300 DIXIE LN S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-3914
Practice Address - Country:US
Practice Address - Phone:727-823-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW24781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3918AOtherBX
FLZ3918AOtherBX