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1205935392

NPI Code Detail

MEDICARE: DR. JERRY EUGENE DAVIS PH.D.

MEDICARE: DR. JERRY EUGENE DAVIS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	39000593A	IN
2	1041C0700X	Clinical Social Worker	34002606A	IN
3	106H00000X	Marriage & Family Therapist	35000571A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000183652	OTHER	IN	ANTHEM BCBS
2	7389148	OTHER	IN	AETNA

General Provider Information

NPI Number	:	1205935392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY EUGENE DAVIS PH.D.

Provider Business Mailing Address
First Line	:	1406 CHERRY ST
Second Line	:
City	:	HUNTINGTON
State	:	IN
Zip	:	46750-1844
Country	:	US
Telephone Number	:	260-356-1605
Fax Number	:

Provider Business Practice Location Address
First Line	:	2821 HILLEGAS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3859
Country	:	US
Telephone Number	:	260-471-1950
Fax Number	:	260-471-1950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	09/11/2025

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Directions to “ DR. JERRY EUGENE DAVIS PH.D.” Practice Location

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