Provider Demographics
NPI:1992015556
Name:PETTY, JERRY LYNN JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:PETTY
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4277 MINGO RD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-3839
Mailing Address - Country:US
Mailing Address - Phone:940-453-9074
Mailing Address - Fax:
Practice Address - Street 1:914 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2954
Practice Address - Country:US
Practice Address - Phone:940-387-6250
Practice Address - Fax:940-387-6274
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional