Healthcare Provider Details

I. General information

NPI: 1841394939
Provider Name (Legal Business Name): JERRY LYNN DOUGLAS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 E LAKESHORE DR SUITE 209
DECATUR IL
62521
US

IV. Provider business mailing address

1770 E LAKESHORE DR SUITE 209
DECATUR IL
62521
US

V. Phone/Fax

Practice location:
  • Phone: 217-423-6500
  • Fax: 217-423-6536
Mailing address:
  • Phone: 217-423-6500
  • Fax: 217-423-6536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number149011257
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: