Provider Demographics
NPI:1972659407
Name:MCCLEOD, JERLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERLYN
Middle Name:
Last Name:MCCLEOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JERLYN
Other - Middle Name:
Other - Last Name:MCCLEOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:101 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6903
Mailing Address - Country:US
Mailing Address - Phone:334-702-7222
Mailing Address - Fax:334-702-1944
Practice Address - Street 1:101 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6903
Practice Address - Country:US
Practice Address - Phone:334-702-7222
Practice Address - Fax:334-702-1944
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL253172084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL127946Medicaid
AL051553959Medicaid
AL631265410OtherEIN
AL051553959Medicare ID - Type Unspecified
AL127946Medicaid