Provider Demographics
NPI:1437336419
Name:AGOSTINI, JACQUELIN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELIN
Middle Name:A
Last Name:AGOSTINI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SILVER HILL LN
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4732
Mailing Address - Country:US
Mailing Address - Phone:856-784-9790
Mailing Address - Fax:
Practice Address - Street 1:1 BRITTON PL
Practice Address - Street 2:SUITE 102
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2514
Practice Address - Country:US
Practice Address - Phone:856-784-9790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100323500103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ789737Medicare PIN