Provider Demographics
NPI:1518108463
Name:STEPHANIDES, JACQUELINE (LPC, LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:STEPHANIDES
Suffix:
Gender:F
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-3044
Mailing Address - Country:US
Mailing Address - Phone:732-996-9442
Mailing Address - Fax:
Practice Address - Street 1:208 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-3044
Practice Address - Country:US
Practice Address - Phone:732-996-9442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003184101YM0800X
NJ37PC00388700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health