Provider Demographics
NPI:1356350912
Name:JEREB, RONALD J (PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:JEREB
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 1:2010 GILMER ROAD
Mailing Address - Street 2:STE 107
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604
Mailing Address - Country:US
Mailing Address - Phone:903-295-3100
Mailing Address - Fax:903-295-3511
Practice Address - Street 1:2010 GILMER ROAD
Practice Address - Street 2:STE 107
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604
Practice Address - Country:US
Practice Address - Phone:903-295-3100
Practice Address - Fax:903-295-3511
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147308401Medicaid
TX147308401Medicaid