Provider Demographics
NPI:1255600383
Name:JEROME, JARED (PHD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:
Last Name:JEROME
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6741 BURNS ST
Mailing Address - Street 2:APT L7
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3542
Mailing Address - Country:US
Mailing Address - Phone:516-633-5662
Mailing Address - Fax:
Practice Address - Street 1:910 W END AVE
Practice Address - Street 2:1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3533
Practice Address - Country:US
Practice Address - Phone:212-662-9200
Practice Address - Fax:212-932-0964
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019401-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical