Provider Demographics
NPI:1285629261
Name:WESCH, JERRY EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:EDWARD
Last Name:WESCH
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 1:2235 WHIPPET WAY
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-5905
Mailing Address - Country:US
Mailing Address - Phone:773-875-5483
Mailing Address - Fax:
Practice Address - Street 1:2235 WHIPPET WAY
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5905
Practice Address - Country:US
Practice Address - Phone:773-875-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-003536103TC0700X, 103TH0100X
AZ4652103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL680014846OtherMEDICARE RR
IL680014846OtherMEDICARE RR