Provider Demographics
NPI:1063008290
Name:LENTZ, JESSICA L
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:LENTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-5721
Mailing Address - Country:US
Mailing Address - Phone:848-468-6863
Mailing Address - Fax:
Practice Address - Street 1:450 QUAKER CHURCH RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-1373
Practice Address - Country:US
Practice Address - Phone:973-298-0763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-20-46426103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst