Provider Demographics
NPI:1235159211
Name:JEROME, JOHN A (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:JEROME
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2740
Mailing Address - Country:US
Mailing Address - Phone:517-337-3080
Mailing Address - Fax:517-337-3082
Practice Address - Street 1:250 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2740
Practice Address - Country:US
Practice Address - Phone:517-337-3080
Practice Address - Fax:517-337-3082
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001259103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680C345670OtherBLUE CROSS BLUE SHIELD
MI680C345670OtherBLUE CROSS BLUE SHIELD
MINPP000Medicare UPIN