Provider Demographics
NPI:1295715019
Name:HERTEL, JAMES BRUCE JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BRUCE
Last Name:HERTEL
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2801 LYNNWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2940
Mailing Address - Country:US
Mailing Address - Phone:573-441-1223
Mailing Address - Fax:573-441-1223
Practice Address - Street 1:1316 OLD HIGHWAY 63 SOUTH
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6092
Practice Address - Country:US
Practice Address - Phone:573-424-2605
Practice Address - Fax:573-441-1223
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO002101101YP2500X
MO2002022912103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist