Provider Demographics
NPI:1427063171
Name:GULLEDGE, JERRY BABB JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:BABB
Last Name:GULLEDGE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:CHIP
Other - Middle Name:
Other - Last Name:GULLEDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3302 S BELT HWY
Mailing Address - Street 2:SUITE P
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64503-1534
Mailing Address - Country:US
Mailing Address - Phone:800-952-8387
Mailing Address - Fax:
Practice Address - Street 1:3302 S BELT HWY
Practice Address - Street 2:SUITE P
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64503-1534
Practice Address - Country:US
Practice Address - Phone:800-952-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06-36P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical