MEDICARE: MR. JERRY MITCHELL EDMONDSON MA, LPC

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	101YP2500X	Professional Counselor	2008012530	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2008012530	OTHER	MO	LICENSED NUMBER FOR STATE OF MISSOURI LICENSED PROFESSIONAL COUNSELOR

General Provider Information

NPI Number	:	1528229598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY MITCHELL EDMONDSON MA, LPC

Provider Business Mailing Address
First Line	:	2849 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2626
Country	:	US
Telephone Number	:	314-910-3099
Fax Number	:

Provider Business Practice Location Address
First Line	:	2849 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2626
Country	:	US
Telephone Number	:	314-910-3099
Fax Number	:

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

Provider Enumeration Date	:	06/22/2008
Last Update Date	:	06/03/2014

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