Provider Demographics
NPI:1417711367
Name:HIBBERT, JERMAINE (LAC)
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:
Last Name:HIBBERT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DODD ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1715
Mailing Address - Country:US
Mailing Address - Phone:917-244-0885
Mailing Address - Fax:
Practice Address - Street 1:935 ALLWOOD RD STE 300
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1988
Practice Address - Country:US
Practice Address - Phone:862-930-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional