Provider Demographics
NPI:1740376409
Name:POWELL, JERRY DEAN (DMIN)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DEAN
Last Name:POWELL
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7429 WILKINS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9434
Mailing Address - Country:US
Mailing Address - Phone:910-309-1574
Mailing Address - Fax:910-323-0310
Practice Address - Street 1:916 ARSENAL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5328
Practice Address - Country:US
Practice Address - Phone:910-309-1574
Practice Address - Fax:910-323-0310
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3565101YP2500X
NC1207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC199121OtherMEDCOST
NC6103661Medicaid