=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811549215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE MARIE PIDICH LPC, ATR- BC, ATCS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 02/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 442 HAMILTON ST APT D
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-630-5322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 442 HAMILTON ST APT D
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-630-5322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number | 15-333
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 37PC00618000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------