Healthcare Provider Details

I. General information

NPI: 1356436075
Provider Name (Legal Business Name): JERRILYN S HERD LMFT,LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MICHIGAN AVE. SUITE 115
LOGANSPORT IN
46947-0000
US

IV. Provider business mailing address

1025 MICHIGAN AVE. SUITE 115
LOGANSPORT IN
46947-0000
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-3566
  • Fax: 574-753-6118
Mailing address:
  • Phone: 574-722-3566
  • Fax: 574-753-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002638A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: