Provider Demographics
NPI:1316969538
Name:SKINNER, JEREMY BURR (PHD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:BURR
Last Name:SKINNER
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 1:211 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4868
Mailing Address - Country:US
Mailing Address - Phone:573-882-4677
Mailing Address - Fax:
Practice Address - Street 1:211 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4868
Practice Address - Country:US
Practice Address - Phone:573-882-4677
Practice Address - Fax:573-882-4583
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0408103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490085012Medicaid