Healthcare Provider Details

I. General information

NPI: 1912908963
Provider Name (Legal Business Name): JERRELL LEE DRIVER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2387 W JACKSON BLVD SUITE B
JACKSON MO
63755-3024
US

IV. Provider business mailing address

POST OFFICE BOX 1642
CAPE GIRARDEAU MO
63702-1642
US

V. Phone/Fax

Practice location:
  • Phone: 573-204-7771
  • Fax: 573-204-7771
Mailing address:
  • Phone: 573-204-7771
  • Fax: 573-204-7771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 00099
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: