Healthcare Provider Details

I. General information

NPI: 1619619657
Provider Name (Legal Business Name): JESSICA WALDRON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FOREST AVE # A
PARAMUS NJ
07652-5429
US

IV. Provider business mailing address

55 IRONWOOD CT
MIDDLETOWN NJ
07748-1916
US

V. Phone/Fax

Practice location:
  • Phone: 201-490-5158
  • Fax: 201-696-3955
Mailing address:
  • Phone: 732-757-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00812500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: