Provider Demographics
NPI:1104367556
Name:MISERENTINO, JESSICA (MED, LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MISERENTINO
Suffix:
Gender:F
Credentials:MED, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SAND SHORE RD
Mailing Address - Street 2:
Mailing Address - City:BUDD LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07828-1506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 SAND SHORE RD
Practice Address - Street 2:
Practice Address - City:BUDD LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07828-1506
Practice Address - Country:US
Practice Address - Phone:862-432-9047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00336000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor