| Doctor Name: | JERRY DAVENPORT |
| NPI Number: | 1043579725 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LAC |
| License Number: | 461 |
| Business Practice Address: | 810 Cedar St Girard, KS - 667432056 |
| Business Phone Number: | 6207248806 |
| Business Fax Number: | 6207246170 |
| Mailing Address: | 911 E Centennial Dr, PITTSBURG |
| State: | KS |
| Postal Code: | 667626601 |
| Phone Number: | 6202315130 |
| Fax Number: | |
| NPI Enumeration Date: | 05/15/2012 |
| NPI Last Update Date: | 05/15/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 461 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KS |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |