Healthcare Provider Details

I. General information

NPI: 1043949514
Provider Name (Legal Business Name): COLLEEN KJEMS LCADC, CCS, NCAC1, I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN KJEMS LCADC, CCS, NCAC1, I

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 HOPE RD STE 5B5A&4A
EATONTOWN NJ
07724-1277
US

IV. Provider business mailing address

28 FOX ST
WHITING NJ
08759-3612
US

V. Phone/Fax

Practice location:
  • Phone: 732-858-5432
  • Fax:
Mailing address:
  • Phone: 848-469-0531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00090000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: