Provider Demographics
NPI:1235606930
Name:BUMSTED-MLECZ, JESSICA ANNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:BUMSTED-MLECZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2243
Mailing Address - Country:US
Mailing Address - Phone:973-341-9869
Mailing Address - Fax:973-689-7271
Practice Address - Street 1:1157 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2243
Practice Address - Country:US
Practice Address - Phone:973-341-9869
Practice Address - Fax:973-689-7271
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ183-077103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling