Provider Demographics
NPI:1881831840
Name:CHERRY, JAY A,
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A,
Last Name:CHERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:ANNA
Other - Last Name:CHERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:901 AVENUE C NW
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-4319
Mailing Address - Country:US
Mailing Address - Phone:940-937-6406
Mailing Address - Fax:940-937-2531
Practice Address - Street 1:4635 SOUTHWEST FWY STE 635
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7112
Practice Address - Country:US
Practice Address - Phone:713-850-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15722101YP2500X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD10119145Medicaid