Provider Demographics
NPI:1851474381
Name:EDIN, JERRY LEE (MS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:EDIN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S 57TH PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-5410
Mailing Address - Country:US
Mailing Address - Phone:541-746-2333
Mailing Address - Fax:
Practice Address - Street 1:525 S 57TH PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-5410
Practice Address - Country:US
Practice Address - Phone:541-746-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0250101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health