Provider Demographics
NPI:1063216588
Name:ANDERSON, JERRY JAY JR
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:JAY
Last Name:ANDERSON
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14799 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2507
Mailing Address - Country:US
Mailing Address - Phone:313-287-4540
Mailing Address - Fax:
Practice Address - Street 1:14799 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2507
Practice Address - Country:US
Practice Address - Phone:313-287-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker