=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104223254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELYN CANTOR RN,CSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2014
-----------------------------------------------------
Last Update Date | 12/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 ROSZEL RD SUITE A103
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-6234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-419-0126
-----------------------------------------------------
Fax | 609-419-0126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 ROSZEL RD SUITE A103
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-6234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-419-0126
-----------------------------------------------------
Fax | 609-419-0126
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 44SW01073100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 26NR08486500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 269645-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------