Jerrell Lee Driver, PHD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PY 00099 Issued in MO

Practice address

2387 W Jackson Blvd
Suite B
Jackson, MO 63755-3024

Phone

(573) 204-7771

Fax

(573) 204-7771

NPI assigned

Aug 2, 2005

Last updated

Sep 10, 2011By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1122940800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1315612800000",
    "number": "1912908963",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "POST OFFICE BOX 1642",
            "city": "CAPE GIRARDEAU",
            "state": "MO",
            "postal_code": "637021642",
            "telephone_number": "573-204-7771",
            "fax_number": "573-204-7771"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2387 W JACKSON BLVD",
            "address_2": "SUITE B",
            "city": "JACKSON",
            "state": "MO",
            "postal_code": "637553024",
            "telephone_number": "573-204-7771",
            "fax_number": "573-204-7771"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DRIVER",
        "first_name": "JERRELL",
        "middle_name": "LEE",
        "name_prefix": "Dr.",
        "credential": "PHD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-08-02",
        "last_updated": "2011-09-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MO",
            "license": "PY 00099",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "493204309",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MO-LICENSE PSYCHOLOGIST",
            "identifier": "PY00099",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Jackson, MO
• Providers in Jackson, MO by specialty
• Clinical Psychologist in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 10, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.