MEDICARE: DR. JERRELL LEE DRIVER PHD

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	103TC0700X	Clinical Psychologist	PY 00099	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PY00099	OTHER		MO-LICENSE PSYCHOLOGIST
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912908963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRELL LEE DRIVER PHD

Provider Business Mailing Address
First Line	:	POST OFFICE BOX 1642
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63702-1642
Country	:	US
Telephone Number	:	573-204-7771
Fax Number	:	573-204-7771

Provider Business Practice Location Address
First Line	:	2387 W JACKSON BLVD
Second Line	:	SUITE B
City	:	JACKSON
State	:	MO
Zip	:	63755-3024
Country	:	US
Telephone Number	:	573-204-7771
Fax Number	:	573-204-7771

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	09/10/2011

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