Healthcare Provider Details

I. General information

NPI: 1720419047
Provider Name (Legal Business Name): MARBLEJAM KIDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 STATE STREET SUITE 204
HACKENSACK NJ
07601
US

IV. Provider business mailing address

214 STATE STREET SUITE 204
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-497-6512
  • Fax: 201-942-4450
Mailing address:
  • Phone: 201-497-6512
  • Fax: 201-942-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0100982978
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerSTATE BUSINESS IDENTIFICATION NUMBER

VIII. Authorized Official

Name: MRS. ANNA FILOMENA VILLA-BAGER
Title or Position: PRESIDENT/ EXEC. DIRECTOR
Credential:
Phone: 201-497-6512