Provider Demographics
NPI:1154100329
Name:GRANT, JEROME (LSW)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:GRANT
Suffix:
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 1:6360 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-1047
Mailing Address - Country:US
Mailing Address - Phone:609-319-7617
Mailing Address - Fax:
Practice Address - Street 1:6360 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330-1047
Practice Address - Country:US
Practice Address - Phone:609-319-7617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06771900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker