Provider Demographics
NPI:1154626547
Name:MCINTOSH, JENNIFER LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 MAIN ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1181
Mailing Address - Country:US
Mailing Address - Phone:732-718-8652
Mailing Address - Fax:
Practice Address - Street 1:318 MAIN ST STE 200A
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1181
Practice Address - Country:US
Practice Address - Phone:973-544-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004301-1171100000X
NJ25MZ00074200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist