Provider Demographics
NPI:1396721353
Name:MARKS, JERRY L (DSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:MARKS
Suffix:
Gender:M
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CREEKSIDE OFFICE DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3290
Mailing Address - Country:US
Mailing Address - Phone:636-887-0914
Mailing Address - Fax:636-206-2522
Practice Address - Street 1:207 CREEKSIDE OFFICE DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3290
Practice Address - Country:US
Practice Address - Phone:636-887-0914
Practice Address - Fax:636-206-2522
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0011201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1172616OtherHEALTHLINK
143828OtherBLUE CROSS