Provider Demographics
NPI:1477965853
Name:CROUCH, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:CROUCH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34394 NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:ANABEL
Mailing Address - State:MO
Mailing Address - Zip Code:63431-2702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1119 S MISSOURI ST STE C
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-1485
Practice Address - Country:US
Practice Address - Phone:660-346-1737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014014453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional