Healthcare Provider Details

I. General information

NPI: 1437294295
Provider Name (Legal Business Name): MR. JERRY THOMAS TRAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S 13TH ST
OZARK MO
65721-8096
US

IV. Provider business mailing address

1401 S 13TH ST
OZARK MO
65721-8096
US

V. Phone/Fax

Practice location:
  • Phone: 417-239-4368
  • Fax: 334-513-1784
Mailing address:
  • Phone: 417-239-4368
  • Fax: 334-513-1784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: