Provider Demographics
NPI:1841394939
Name:DOUGLAS, JERRY LYNN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LCSW
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Mailing Address - Street 1:1770 E LAKESHORE DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521
Mailing Address - Country:US
Mailing Address - Phone:217-423-6500
Mailing Address - Fax:217-423-6536
Practice Address - Street 1:1770 E LAKESHORE DR
Practice Address - Street 2:SUITE 209
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-423-6500
Practice Address - Fax:217-423-6536
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL1490112572084P0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15868Medicare PIN