Provider Demographics
NPI:1841935236
Name:HARTWELL, JERLEEL
Entity type:Individual
Prefix:
First Name:JERLEEL
Middle Name:
Last Name:HARTWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 S 216TH LN
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-8030
Mailing Address - Country:US
Mailing Address - Phone:602-620-4377
Mailing Address - Fax:
Practice Address - Street 1:11630 W BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-3915
Practice Address - Country:US
Practice Address - Phone:602-622-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1234567Medicaid