Healthcare Provider Details

I. General information

NPI: 1326584350
Provider Name (Legal Business Name): KYLE JORDAN MCDERMOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2017
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 E BROADWAY
SALEM NJ
08079-1108
US

IV. Provider business mailing address

PO BOX 1309
MARLTON NJ
08053-6309
US

V. Phone/Fax

Practice location:
  • Phone: 856-935-7711
  • Fax: 856-935-9123
Mailing address:
  • Phone: 609-567-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: