Provider Demographics
NPI:1417481730
Name:JERSCHINA, GRACEL (LAC)
Entity Type:Individual
Prefix:
First Name:GRACEL
Middle Name:
Last Name:JERSCHINA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 BROADWAY
Mailing Address - Street 2:APT 6B
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-1969
Mailing Address - Country:US
Mailing Address - Phone:616-558-6388
Mailing Address - Fax:
Practice Address - Street 1:22-08 ROUTE 208
Practice Address - Street 2:SUITE 16
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2609
Practice Address - Country:US
Practice Address - Phone:616-655-8638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00337100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health