Provider Demographics
NPI:1225189152
Name:WHITEHEAD, JESSE JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:WHITEHEAD
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-2804
Mailing Address - Country:US
Mailing Address - Phone:732-542-5925
Mailing Address - Fax:732-542-5841
Practice Address - Street 1:15 CANTERBURY LN
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-2804
Practice Address - Country:US
Practice Address - Phone:732-542-5925
Practice Address - Fax:732-542-5841
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00208700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3475107Medicaid
NJ088684Medicare ID - Type UnspecifiedIDENTIFICATION CODE