Provider Demographics
NPI:1750975785
Name:EVANS, JERRY JR (LMHC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 FAIRPORT VILLAGE LNDG # 109
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1804
Mailing Address - Country:US
Mailing Address - Phone:585-200-7106
Mailing Address - Fax:973-253-4500
Practice Address - Street 1:46 PRINCE ST # LL001
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1023
Practice Address - Country:US
Practice Address - Phone:585-200-7106
Practice Address - Fax:973-253-4500
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2874101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health