Healthcare Provider Details

I. General information

NPI: 1235909201
Provider Name (Legal Business Name): JENA JAKE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 OCEAN AVE UNIT 6J
MONMOUTH BEACH NJ
07750-2404
US

IV. Provider business mailing address

174 NASSAU ST STE 274
PRINCETON NJ
08542-7005
US

V. Phone/Fax

Practice location:
  • Phone: 732-682-3111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number37AC00106600
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: