Provider Demographics
NPI:1235909201
Name:JAKE, JENA (LAC)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:JAKE
Suffix:
Gender:
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 NASSAU ST STE 274
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08542-7005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 OCEAN AVE UNIT 6J
Practice Address - Street 2:
Practice Address - City:MONMOUTH BEACH
Practice Address - State:NJ
Practice Address - Zip Code:07750-2404
Practice Address - Country:US
Practice Address - Phone:732-682-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 101Y00000X
NJ37AC00106600103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling