Provider Demographics
NPI:1083763197
Name:STETTHEIMER, JERRY (D MIN)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:STETTHEIMER
Suffix:
Gender:M
Credentials:D MIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E INTERSTATE 30
Mailing Address - Street 2:SUITE M 107
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-8000
Mailing Address - Country:US
Mailing Address - Phone:972-226-8846
Mailing Address - Fax:
Practice Address - Street 1:310 E INTERSTATE 30
Practice Address - Street 2:SUITE M 107
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-8000
Practice Address - Country:US
Practice Address - Phone:972-226-8846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX384106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist