Healthcare Provider Details

I. General information

NPI: 1215925706
Provider Name (Legal Business Name): JERREL EDWARD IVEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6324 WOODMERE BLVD
MONTGOMERY AL
36117-2537
US

IV. Provider business mailing address

PO BOX 230310
MONTGOMERY AL
36123-0310
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-3889
  • Fax: 334-272-4089
Mailing address:
  • Phone: 334-272-3889
  • Fax: 334-272-4089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC #1147
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: