Provider Demographics
NPI:1194914101
Name:JERRY L. HART PH.D. CLINICAL PSYCHOLOGIST P.C.
Entity type:Organization
Organization Name:JERRY L. HART PH.D. CLINICAL PSYCHOLOGIST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:205-556-7145
Mailing Address - Street 1:701 UNIVERSITY BLVD E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2086
Mailing Address - Country:US
Mailing Address - Phone:205-556-7145
Mailing Address - Fax:205-553-9127
Practice Address - Street 1:701 UNIVERSITY BLVD E
Practice Address - Street 2:SUITE 204
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2086
Practice Address - Country:US
Practice Address - Phone:205-556-7145
Practice Address - Fax:205-553-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL306103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR35732Medicare UPIN
AL000070775Medicare PIN