Provider Demographics
NPI:1255728895
Name:LOVORN, JERRY (MA, LPC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:LOVORN
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 TABBY DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-9787
Mailing Address - Country:US
Mailing Address - Phone:601-562-9126
Mailing Address - Fax:
Practice Address - Street 1:203 TABBY DR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-9787
Practice Address - Country:US
Practice Address - Phone:601-562-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional