Healthcare Provider Details

I. General information

NPI: 1811173339
Provider Name (Legal Business Name): MRS. JEAN EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E MADISON AVE
MAGNOLIA NJ
08049-1409
US

IV. Provider business mailing address

437 ROOSEVELT AVE
GLENDORA NJ
08029-1033
US

V. Phone/Fax

Practice location:
  • Phone: 856-541-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: