Provider Demographics
NPI:1811024730
Name:PETERS, JERRY B (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:PETERS
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 1:1734 E 63RD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-3543
Mailing Address - Country:US
Mailing Address - Phone:816-333-9999
Mailing Address - Fax:816-333-1943
Practice Address - Street 1:1734 E 63RD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3543
Practice Address - Country:US
Practice Address - Phone:816-333-9999
Practice Address - Fax:816-333-1943
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002286101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)