Provider Demographics
NPI:1144348061
Name:ANDERSON, JERRY RONALD (LPC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:RONALD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:RICE
Mailing Address - State:TX
Mailing Address - Zip Code:75155-0187
Mailing Address - Country:US
Mailing Address - Phone:903-654-2064
Mailing Address - Fax:
Practice Address - Street 1:800 N MAIN ST
Practice Address - Street 2:SUITE N
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-3031
Practice Address - Country:US
Practice Address - Phone:903-654-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional