Healthcare Provider Details

I. General information

NPI: 1356126155
Provider Name (Legal Business Name): DAVID JEROME WHITE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 09/02/2023
Certification Date: 09/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 15245
APO AP
96271-5245
US

IV. Provider business mailing address

1733 PLEASONTON RD # 6330
EL PASO TX
79906-3800
US

V. Phone/Fax

Practice location:
  • Phone: 317-737-1411
  • Fax:
Mailing address:
  • Phone: 870-945-5806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC22125
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: