Provider Demographics
NPI:1205225877
Name:BECERRA, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:BECERRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 KINDERKAMACK RD
Mailing Address - Street 2:P.O. BOX#126
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-2126
Mailing Address - Country:US
Mailing Address - Phone:201-391-1355
Mailing Address - Fax:201-391-9516
Practice Address - Street 1:114 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-2126
Practice Address - Country:US
Practice Address - Phone:201-391-1355
Practice Address - Fax:201-391-9516
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL051803001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical