Basic Information
| Provider Information | |||||||||
| NPI: | 1669574687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | THOMPSON | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M. ED., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 616 ASHDALE DR | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299072509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438163421 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1050 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435243378 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 05/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2644 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC001967 | GA | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.