Provider Demographics
NPI:1619651577
Name:MCCALLA, JEROME WESLEY
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:WESLEY
Last Name:MCCALLA
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 1:212 SPRUCE TRL
Mailing Address - Street 2:
Mailing Address - City:SWEDESBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-4008
Mailing Address - Country:US
Mailing Address - Phone:215-275-1999
Mailing Address - Fax:
Practice Address - Street 1:212 SPRUCE TRL
Practice Address - Street 2:
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-4008
Practice Address - Country:US
Practice Address - Phone:215-275-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child