Healthcare Provider Details

I. General information

NPI: 1295413755
Provider Name (Legal Business Name): LAUREN DIANE JACQUEMIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 OLD MARLTON PIKE STE 101
MEDFORD NJ
08055-8772
US

IV. Provider business mailing address

33 GREENBROOK DR
COLUMBUS NJ
08022-2319
US

V. Phone/Fax

Practice location:
  • Phone: 856-223-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00758800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00253300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: