Provider Demographics
NPI:1538582291
Name:NEWPORT, JERRY
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:NEWPORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 N. YELLOW SPRINGS
Mailing Address - Street 2:MENTAL HEALTH SERVICES FOR CLARK AND MADISON COUNTIES
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504
Mailing Address - Country:US
Mailing Address - Phone:937-399-9500
Mailing Address - Fax:937-342-4242
Practice Address - Street 1:474 N. YELLOW SPRINGS ST
Practice Address - Street 2:MENTAL HEALTH SERVICES FOR CLARK AND MADISON COUNTIES
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504
Practice Address - Country:US
Practice Address - Phone:937-399-9500
Practice Address - Fax:937-342-4242
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-0001738-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health