Provider Demographics
NPI:1912908963
Name:DRIVER, JERRELL LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRELL
Middle Name:LEE
Last Name:DRIVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 1642
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-1642
Mailing Address - Country:US
Mailing Address - Phone:573-204-7771
Mailing Address - Fax:573-204-7771
Practice Address - Street 1:2387 W JACKSON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3024
Practice Address - Country:US
Practice Address - Phone:573-204-7771
Practice Address - Fax:573-204-7771
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2011-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY 00099103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PY00099OtherMO-LICENSE PSYCHOLOGIST
MO493204309Medicaid
PY00099OtherMO-LICENSE PSYCHOLOGIST