Provider Demographics
NPI:1801932124
Name:PAYNE, JERALD (LSCSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JERALD
Middle Name:
Last Name:PAYNE
Suffix:
Gender:M
Credentials:LSCSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2925
Mailing Address - Country:US
Mailing Address - Phone:816-864-4201
Mailing Address - Fax:816-561-8199
Practice Address - Street 1:3914 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2925
Practice Address - Country:US
Practice Address - Phone:816-864-4201
Practice Address - Fax:816-561-8199
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010318251041C0700X
KS21691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495380420Medicaid
KS200256670-AMedicaid
MO495380404Medicaid