Provider Demographics
NPI:1609214964
Name:JUSTICE, JEREMIAH L (MHP)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:L
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 GREENWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3437
Practice Address - Country:US
Practice Address - Phone:815-338-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker