Provider Demographics
NPI:1902204035
Name:WHITEKETTLE, ROBERT JR (LSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:WHITEKETTLE
Suffix:JR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 STANFORD RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2620
Mailing Address - Country:US
Mailing Address - Phone:856-448-2325
Mailing Address - Fax:
Practice Address - Street 1:333 IRVING AVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2123
Practice Address - Country:US
Practice Address - Phone:856-575-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06011900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker