Provider Demographics
NPI:1932249935
Name:HERTER, JACQUES P (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:P
Last Name:HERTER
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 1:535 W YELLOWSTONE HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-7508
Mailing Address - Country:US
Mailing Address - Phone:307-235-9004
Mailing Address - Fax:866-467-2018
Practice Address - Street 1:535 W YELLOWSTONE HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-7507
Practice Address - Country:US
Practice Address - Phone:307-235-9004
Practice Address - Fax:866-467-2018
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY93103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYR04574Medicare UPIN