Provider Demographics
NPI:1811941420
Name:MUSGRAVE, JAY BRADLEY (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:BRADLEY
Last Name:MUSGRAVE
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 KINGSWAY DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-3603
Mailing Address - Country:US
Mailing Address - Phone:573-651-4206
Mailing Address - Fax:573-339-0053
Practice Address - Street 1:1221 KINGSWAY DR
Practice Address - Street 2:SUITE 5
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-3603
Practice Address - Country:US
Practice Address - Phone:573-651-4206
Practice Address - Fax:573-339-0053
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000568101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5634OtherBLUE CROSS