Provider Demographics
NPI:1255111563
Name:JAMES, EDGAR JEROME (LMSW)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:JEROME
Last Name:JAMES
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ENDRES DR APT 2
Mailing Address - Street 2:
Mailing Address - City:MATTYDALE
Mailing Address - State:NY
Mailing Address - Zip Code:13211-1134
Mailing Address - Country:US
Mailing Address - Phone:229-539-6873
Mailing Address - Fax:
Practice Address - Street 1:112 ENDRES DR APT 2
Practice Address - Street 2:
Practice Address - City:MATTYDALE
Practice Address - State:NY
Practice Address - Zip Code:13211-1134
Practice Address - Country:US
Practice Address - Phone:229-539-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121516104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker