Healthcare Provider Details

I. General information

NPI: 1962801266
Provider Name (Legal Business Name): JERUSHA ELISSE HULL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JERUSA BROWN LICSW

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

3213 12TH ST. NE #101
WASHINGTON DC
20017
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8149
  • Fax:
Mailing address:
  • Phone: 254-716-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number54787
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50080654
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008947
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: