Provider Demographics
NPI:1205935392
Name:DAVIS, JERRY EUGENE (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:EUGENE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-1844
Mailing Address - Country:US
Mailing Address - Phone:260-356-1605
Mailing Address - Fax:
Practice Address - Street 1:2821 HILLEGAS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3859
Practice Address - Country:US
Practice Address - Phone:260-471-1950
Practice Address - Fax:260-471-1950
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000593A101YM0800X
IN34002606A1041C0700X
IN35000571A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000183652OtherANTHEM BCBS
IN7389148OtherAETNA
IN7389148OtherAETNA