Provider Demographics
NPI:1972696896
Name:O'BRIEN, C GERALD JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:C
Middle Name:GERALD
Last Name:O'BRIEN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:640 LAKELAND EAST DRIVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9778
Mailing Address - Country:US
Mailing Address - Phone:601-664-6730
Mailing Address - Fax:601-664-6732
Practice Address - Street 1:640 LAKELAND EAST DRIVE
Practice Address - Street 2:SUITE F
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9778
Practice Address - Country:US
Practice Address - Phone:601-664-6730
Practice Address - Fax:601-664-6732
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15-167103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist