MEDICARE: JERRY WAYNE OLIVE LPC

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	101YM0800X	Mental Health Counselor	2009012865	MO

General Provider Information

NPI Number	:	1437422813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY WAYNE OLIVE LPC

Provider Business Mailing Address
First Line	:	301 SOVEREIGN CT
Second Line	:	SUITE 105
City	:	BALLWIN
State	:	MO
Zip	:	63011-4441
Country	:	US
Telephone Number	:	636-448-5184
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 SOVEREIGN CT
Second Line	:	SUITE 105
City	:	BALLWIN
State	:	MO
Zip	:	63011-4441
Country	:	US
Telephone Number	:	636-448-5184
Fax Number	:

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

Provider Enumeration Date	:	02/16/2012
Last Update Date	:	02/16/2012

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