MEDICARE: MS. JESSICA DISLA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1295891927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA DISLA LCSW

Provider Business Mailing Address
First Line	:	275 GRAND AVE APT 16A
Second Line	:
City	:	ENGLEWOOD
State	:	NJ
Zip	:	07631-4389
Country	:	US
Telephone Number	:	201-408-4071
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5943
Country	:	US
Telephone Number	:	201-761-6417
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	02/24/2011

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