=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508243908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUES HRYSHKO MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2015
-----------------------------------------------------
Last Update Date | 05/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 HILTON AVE
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-762-8734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 HILTON AVE
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-762-8734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 37PC00212600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 37PC00212600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37PC00212600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 37PC00212600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------