Provider Demographics
NPI:1164057923
Name:LUM, JENISE (PHD)
Entity Type:Individual
Prefix:
First Name:JENISE
Middle Name:
Last Name:LUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1683 ROUTE 88 W
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3072
Mailing Address - Country:US
Mailing Address - Phone:732-840-5266
Mailing Address - Fax:
Practice Address - Street 1:1683 ROUTE 88 W
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3072
Practice Address - Country:US
Practice Address - Phone:732-840-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
NJ35SI00623100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist