Provider Demographics
NPI:1619625563
Name:JOSE, MARY JEAN (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:JOSE
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 1:619 BERNITA DR
Mailing Address - Street 2:
Mailing Address - City:RIVER VALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-5905
Mailing Address - Country:US
Mailing Address - Phone:732-689-0171
Mailing Address - Fax:
Practice Address - Street 1:619 BERNITA DR
Practice Address - Street 2:
Practice Address - City:RIVER VALE
Practice Address - State:NJ
Practice Address - Zip Code:07675-5905
Practice Address - Country:US
Practice Address - Phone:732-689-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00490600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health