Provider Demographics
NPI:1083948459
Name:MACK, JESSICA V
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:V
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:V
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:205 2ND AVE
Mailing Address - Street 2:APT. 4E
Mailing Address - City:BELMAR
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-2070
Mailing Address - Country:US
Mailing Address - Phone:908-770-2843
Mailing Address - Fax:
Practice Address - Street 1:205 2ND AVE
Practice Address - Street 2:APT. 4E
Practice Address - City:BELMAR
Practice Address - State:NJ
Practice Address - Zip Code:07719-2070
Practice Address - Country:US
Practice Address - Phone:908-770-2843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst