MEDICARE: JEROME JOHNSON GRIFFIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW025544	PA

General Provider Information

NPI Number	:	1639551153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEROME JOHNSON GRIFFIN

Provider Business Mailing Address
First Line	:	26 N MILLBOURNE AVE
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-1812
Country	:	US
Telephone Number	:	610-931-3312
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 N MILLBOURNE AVE
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-1812
Country	:	US
Telephone Number	:	610-931-3312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2015
Last Update Date	:	03/20/2025

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