Healthcare Provider Details

I. General information

NPI: 1093216962
Provider Name (Legal Business Name): JESSICA FAWN AMBROSINI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 UNION AVE
RUTHERFORD NJ
07070-1275
US

IV. Provider business mailing address

210 BOULEVARD FL 2
HASBROUCK HEIGHTS NJ
07604-1802
US

V. Phone/Fax

Practice location:
  • Phone: 201-399-7225
  • Fax:
Mailing address:
  • Phone: 201-286-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL05792200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: