=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942617212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEARL JERRI CROSS ED.S,LPC/MHSP, CPSII
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2014
-----------------------------------------------------
Last Update Date | 07/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 441 E BROAD ST SUITE B
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-3389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-214-0527
-----------------------------------------------------
Fax | 931-520-0767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 441 E BROAD ST SUITE B
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-3389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-214-0527
-----------------------------------------------------
Fax | 931-520-0767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC0000003149
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------