Basic Information
| Provider Information | |||||||||
| NPI: | 1811476112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARPE | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PSS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 GUNNELL RD | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975269621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414410716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 806 NW 6TH ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412375171 | ||||||||
| FaxNumber: | 5414792370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP1600X | N | Behavioral Health & Social Service Providers | Counselor | Pastoral | 247000000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | 175T00000X | OR | Y |
No ID Information.