Healthcare Provider Details

I. General information

NPI: 1235606930
Provider Name (Legal Business Name): JESSICA ANNE BUMSTED-MLECZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 MAIN AVE
CLIFTON NJ
07011-2243
US

IV. Provider business mailing address

1157 MAIN AVE
CLIFTON NJ
07011-2243
US

V. Phone/Fax

Practice location:
  • Phone: 973-341-9869
  • Fax: 973-689-7271
Mailing address:
  • Phone: 973-341-9869
  • Fax: 973-689-7271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number183-077
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: