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General NPI Number Information
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NPI Number | 1760285027
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Entity Type | Individual
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Provider Name | JESSICA DISTEFANO MS, LAC
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Gender | Female
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Dates
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Enumeration Date | 03/31/2025
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 800 W MAIN ST STE 205
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City | FREEHOLD
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State | NJ
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Zip | 07728-2555
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Country | US
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Telephone | 732-655-6331
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Fax |
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Provider Business Mailing Address
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Address Line | 706 LAREINE AVE UNIT 318
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City | BRADLEY BEACH
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State | NJ
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Zip | 07720-1065
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Country | US
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Telephone | 732-674-3255
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 37AC00782300
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License Number State | NJ
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