=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831386747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY HAMILTON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7165 GETWELL RD
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-349-2818
-----------------------------------------------------
Fax | 662-342-3406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7165 GETWELL DRIVE
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38109-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-345-0636
-----------------------------------------------------
Fax | 662-772-3259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3165
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1502
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------