Provider Demographics
NPI:1659381606
Name:BRUCKER, JERROLD LEE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JERROLD
Middle Name:LEE
Last Name:BRUCKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 S PIKE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-7650
Mailing Address - Country:US
Mailing Address - Phone:610-730-2744
Mailing Address - Fax:
Practice Address - Street 1:1101 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6046
Practice Address - Country:US
Practice Address - Phone:610-730-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0145571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0070975930002Medicaid
PAR06879Medicare UPIN
PA0070975930002Medicaid