=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871088955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLESSINGS WAY BEHAVIORAL HEALTH, CDC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2018
-----------------------------------------------------
Last Update Date | 06/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 HAMILTON AVE STE 108
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-1054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-788-0313
-----------------------------------------------------
Fax | 609-788-4505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 PEACH TREE LN
-----------------------------------------------------
City | EGG HARBOR TWP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08234-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-350-5817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/FOUNDER
-----------------------------------------------------
Name | MARY L JENNINGS
-----------------------------------------------------
Credential | APN
-----------------------------------------------------
Telephone | 609-350-5817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ006500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------