Provider Demographics
NPI:1215996095
Name:WHITEMAN, JERRY L (PHD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:WHITEMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 4TH AVE
Mailing Address - Street 2:150
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7887
Mailing Address - Country:US
Mailing Address - Phone:337-477-7091
Mailing Address - Fax:337-474-4552
Practice Address - Street 1:2829 4TH AVE
Practice Address - Street 2:150
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7887
Practice Address - Country:US
Practice Address - Phone:337-477-7091
Practice Address - Fax:337-474-4552
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA407103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1125466Medicaid
LA5632157563Medicare ID - Type Unspecified