Healthcare Provider Details

I. General information

NPI: 1417834615
Provider Name (Legal Business Name): JORDAN MADISON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E RIDGEWOOD AVE STE 415
PARAMUS NJ
07652-3915
US

IV. Provider business mailing address

5 PITCAIRN AVE
HO HO KUS NJ
07423-1622
US

V. Phone/Fax

Practice location:
  • Phone: 201-820-7380
  • Fax:
Mailing address:
  • Phone: 201-820-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00902800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: