Provider Demographics
NPI:1699445742
Name:BASS, JERALD FRANKLIN JR
Entity type:Individual
Prefix:MR
First Name:JERALD
Middle Name:FRANKLIN
Last Name:BASS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4070 BARRETT DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6604
Mailing Address - Country:US
Mailing Address - Phone:919-283-3137
Mailing Address - Fax:
Practice Address - Street 1:4070 BARRETT DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6604
Practice Address - Country:US
Practice Address - Phone:919-283-3137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16993101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health