Healthcare Provider Details

I. General information

NPI: 1568325397
Provider Name (Legal Business Name): JESSICA R DEMO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 AUTUMN CREST DR
WATERFORD WORKS NJ
08089-2131
US

IV. Provider business mailing address

623 AUTUMN CREST DR
WATERFORD WORKS NJ
08089-2131
US

V. Phone/Fax

Practice location:
  • Phone: 609-464-4289
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL07237200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: