MEDICARE: DR. JESSICA JEAN AUTH PH.D.

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	103TC2200X	Clinical Child & Adolescent Psychologist	015883	NY
2	103T00000X	Psychologist	4777	NJ

General Provider Information

NPI Number	:	1760469845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA JEAN AUTH PH.D.

Provider Business Mailing Address
First Line	:	28 MILLBURN AVE
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-1039
Country	:	US
Telephone Number	:	973-467-9333
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 MILLBURN AVE
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-1039
Country	:	US
Telephone Number	:	973-467-9333
Fax Number	:

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	06/12/2012

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