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General NPI Number Information
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NPI Number | 1750975785
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Entity Type | Individual
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Provider Name | JERRY EVANS JR. LMHC
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Gender | Male
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Dates
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Enumeration Date | 02/20/2021
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Last Update Date | 02/20/2021
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Provider Practice Location Address
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Address Line | 46 PRINCE ST # LL001
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City | ROCHESTER
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State | NY
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Zip | 14607-1023
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Country | US
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Telephone | 585-200-7106
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Fax | 973-253-4500
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Provider Business Mailing Address
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Address Line | 144 FAIRPORT VILLAGE LNDG # 109
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City | FAIRPORT
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State | NY
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Zip | 14450-1804
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Country | US
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Telephone | 585-200-7106
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Fax | 973-253-4500
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2874
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License Number State | NY
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