=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578216248
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ALEXANDRIA AHEARN MA, LAC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2022
-----------------------------------------------------
Last Update Date | 02/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1806 ROUTE 35 STE 205C
-----------------------------------------------------
City | OAKHURST
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07755-2759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-863-9728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 EMMA PL
-----------------------------------------------------
City | EATONTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07724-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-832-5873
-----------------------------------------------------
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 | 37AC00622700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------