Provider Demographics
NPI:1447670237
Name:BALLAS, JENNIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:
Last Name:BALLAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 EAGLES NOTCH DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-5061
Mailing Address - Country:US
Mailing Address - Phone:201-745-7368
Mailing Address - Fax:
Practice Address - Street 1:75 EAGLES NOTCH DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-5061
Practice Address - Country:US
Practice Address - Phone:201-745-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00473800101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor