Healthcare Provider Details

I. General information

NPI: 1417634841
Provider Name (Legal Business Name): ASHLEY STARR JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLEY STARR MITRICKA

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 STATE ROUTE 35
CLIFFWOOD NJ
07721-1512
US

IV. Provider business mailing address

275 LAURENCE PKWY # B
LAURENCE HARBOR NJ
08879-2766
US

V. Phone/Fax

Practice location:
  • Phone: 732-812-5489
  • Fax: 732-566-1937
Mailing address:
  • Phone: 908-451-4120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: