Provider Demographics
NPI:1447405527
Name:PROVANCE, JEAN LOUISE (MSW, LCSW)
Entity Type:Individual
Prefix:MISS
First Name:JEAN
Middle Name:LOUISE
Last Name:PROVANCE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:NICOLE
Other - Last Name:PETELA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:807 CRANBURY CROSS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-2268
Mailing Address - Country:US
Mailing Address - Phone:908-510-0532
Mailing Address - Fax:
Practice Address - Street 1:807 CRANBURY CROSS RD
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-2268
Practice Address - Country:US
Practice Address - Phone:908-510-0532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054735001041C0700X
NJ44SL055245000104100000X
NY077689-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker