Provider Demographics
NPI:1093216962
Name:AMBROSINI, JESSICA FAWN (LSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAWN
Last Name:AMBROSINI
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BOULEVARD FL 2
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1802
Mailing Address - Country:US
Mailing Address - Phone:201-286-5910
Mailing Address - Fax:
Practice Address - Street 1:145 MORTIMER AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-1614
Practice Address - Country:US
Practice Address - Phone:201-399-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL057922001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical