Provider Demographics
NPI:1033651781
Name:DERRICK, JEROME
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:DERRICK
Suffix:
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 1:401 US HIGHWAY 22 W APT F
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-3805
Mailing Address - Country:US
Mailing Address - Phone:973-652-7764
Mailing Address - Fax:
Practice Address - Street 1:401 US HIGHWAY 22 W APT F
Practice Address - Street 2:
Practice Address - City:NORTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-3805
Practice Address - Country:US
Practice Address - Phone:973-652-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-12
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)