Provider Demographics
NPI:1235378258
Name:WYATT, JERMAINE (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MICHIGAN AVE NE
Mailing Address - Street 2:#T12
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-1039
Mailing Address - Country:US
Mailing Address - Phone:202-569-9539
Mailing Address - Fax:
Practice Address - Street 1:140 MICHIGAN AVE NE
Practice Address - Street 2:#T12
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-1039
Practice Address - Country:US
Practice Address - Phone:202-569-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-14
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical