Healthcare Provider Details

I. General information

NPI: 1104916329
Provider Name (Legal Business Name): JEROME NICHOLAS HIRE L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HAVEN DR
DOTHAN AL
36301-2919
US

IV. Provider business mailing address

817 COUNTY ROAD 6
BLACK AL
36314-5311
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-1964
  • Fax: 334-794-4131
Mailing address:
  • Phone: 334-684-6373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0753C
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: