Healthcare Provider Details

I. General information

NPI: 1750516027
Provider Name (Legal Business Name): JERRI SHANKLER MSW LCSW LCADC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 VALLEY DR
GLENWOOD NJ
07418-1657
US

IV. Provider business mailing address

25 VALLEY DR
GLENWOOD NJ
07418-1657
US

V. Phone/Fax

Practice location:
  • Phone: 201-452-1432
  • Fax:
Mailing address:
  • Phone: 201-452-1432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04391600
License Number StateNJ

VIII. Authorized Official

Name: MS. JERRI SHANKLER
Title or Position: OWNER
Credential: MSW LCSW LCADC
Phone: 201-452-1432