Provider Demographics
NPI:1447812656
Name:PERSICO, JACQUELINE (EDS, LAC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:PERSICO
Suffix:
Gender:F
Credentials:EDS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PRESCOTT CT
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-2983
Mailing Address - Country:US
Mailing Address - Phone:973-641-5967
Mailing Address - Fax:
Practice Address - Street 1:1 W CLIFF ST FL 1
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-1901
Practice Address - Country:US
Practice Address - Phone:908-399-9024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00467800101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor