Provider Demographics
NPI:1831386747
Name:HAMILTON, JERRY (LCSW)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7165 GETWELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38109-1722
Mailing Address - Country:US
Mailing Address - Phone:901-345-0636
Mailing Address - Fax:662-772-3259
Practice Address - Street 1:7165 GETWELL RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9618
Practice Address - Country:US
Practice Address - Phone:662-349-2818
Practice Address - Fax:662-342-3406
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31651041C0700X
AR15021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3699016Medicaid
TN568759-000OtherMAGELLAN HEALTH CARE
TN11549639OtherCAQH AETNA
TN4114450OtherBLUE CROSS BLUE SHIELD