MEDICARE: MR. JERRY BEN MORRIS B.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility		TX

General Provider Information

NPI Number	:	1295922185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY BEN MORRIS B.S.

Provider Business Mailing Address
First Line	:	6901 REBEL RD
Second Line	:
City	:	FOREST HILL
State	:	TX
Zip	:	76140-1815
Country	:	US
Telephone Number	:	817-293-7347
Fax Number	:	817-926-7461

Provider Business Practice Location Address
First Line	:	1333 E RICHMOND AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-6116
Country	:	US
Telephone Number	:	817-926-7041
Fax Number	:	817-926-7461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	11/13/2007

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