Provider Demographics
NPI:1730227372
Name:ALDRICH, JON GERALD (LICSW)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:GERALD
Last Name:ALDRICH
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W PARK ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1378
Mailing Address - Country:US
Mailing Address - Phone:603-448-4370
Mailing Address - Fax:603-448-4370
Practice Address - Street 1:20 W PARK ST
Practice Address - Street 2:SUITE 214
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1378
Practice Address - Country:US
Practice Address - Phone:603-448-4370
Practice Address - Fax:603-448-4370
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1408363Y0NH01OtherANTHEM
NH341027OtherMVP HEALTH CARE
VTOVN-0653Medicaid
NH30006909Medicaid
VT29080OtherVT BLUE SHIELD
NHH08421OtherCHAMPUS
NH1408363Y0NH01OtherANTHEM