Provider Demographics
NPI:1043757990
Name:JERSEY INNOVATIVE SERVICES LLC
Entity Type:Organization
Organization Name:JERSEY INNOVATIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-614-6145
Mailing Address - Street 1:2360 LAKEWOOD RD
Mailing Address - Street 2:SUITE 3 #256
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-1929
Mailing Address - Country:US
Mailing Address - Phone:732-614-6145
Mailing Address - Fax:732-612-1162
Practice Address - Street 1:2360 LAKEWOOD RD
Practice Address - Street 2:SUITE 3 #256
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-1929
Practice Address - Country:US
Practice Address - Phone:732-614-6145
Practice Address - Fax:732-612-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJXXX251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0169994Medicaid