Provider Demographics
NPI:1962436832
Name:WARD, JERRY TODD (LCSW)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:TODD
Last Name:WARD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BELINDA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-3217
Mailing Address - Country:US
Mailing Address - Phone:859-209-4286
Mailing Address - Fax:859-209-4278
Practice Address - Street 1:185 TREUHAFT BLVD
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-8303
Practice Address - Country:US
Practice Address - Phone:606-546-2757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1197004OtherCHA
541568OtherVALUE OPTIONS
KY30610026Medicaid
800013193OtherPALMETTO - RR MCR
000000227561OtherANTHEM BCBS
279367OtherMANAGED HEALTH
279367OtherMANAGED HEALTH
P54232Medicare UPIN