Provider Demographics
NPI:1073861209
Name:DEBENEDETTO, JILLIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:DEBENEDETTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5802
Mailing Address - Country:US
Mailing Address - Phone:732-610-3238
Mailing Address - Fax:
Practice Address - Street 1:FORT HEALTH MEDICAL GROUP 613 WASHING BLVD.
Practice Address - Street 2:#1297
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:10314-1509
Practice Address - Country:US
Practice Address - Phone:201-208-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ44SC061437001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program