Healthcare Provider Details

I. General information

NPI: 1588579775
Provider Name (Legal Business Name): OUR SPACE NORTHEAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3199
US

IV. Provider business mailing address

130 W PLEASANT AVE STE 85
MAYWOOD NJ
07607-1335
US

V. Phone/Fax

Practice location:
  • Phone: 201-714-0820
  • Fax:
Mailing address:
  • Phone: 201-714-0820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUELINE COLLARD
Title or Position: OWNER/LCSW
Credential: DSW, LCSW
Phone: 908-721-6728