Provider Demographics
NPI:1275127946
Name:RE, JACKIE (LCADC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:RE
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MOHICAN RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825-9687
Mailing Address - Country:US
Mailing Address - Phone:908-295-8097
Mailing Address - Fax:
Practice Address - Street 1:100 MOHICAN RD
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825-9687
Practice Address - Country:US
Practice Address - Phone:908-295-8097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00325900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)