Basic Information
| Provider Information | |||||||||
| NPI: | 1881062131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNP, PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 S 2ND ST | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041612 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 S FRONT ST | ||||||||
| Address2: | 5TH FLOOR, BMA | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318360 | ||||||||
| FaxNumber: | 7172318358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | SP015212 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | SP015212 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 103050582 | 05 | PA | MEDICAID |