Provider Demographics
NPI:1972150894
Name:SEALE, JERRY MICHAEL
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:SEALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33023
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-3023
Mailing Address - Country:US
Mailing Address - Phone:865-789-5352
Mailing Address - Fax:
Practice Address - Street 1:4706 PAPERMILL DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1972
Practice Address - Country:US
Practice Address - Phone:865-789-5352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0062106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist