Provider Demographics
NPI:1629489216
Name:PETAK JACOWITZ, ELLEN I (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:PETAK JACOWITZ
Suffix:I
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 OLD HOOK RD
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1381
Mailing Address - Country:US
Mailing Address - Phone:646-335-2221
Mailing Address - Fax:
Practice Address - Street 1:452 OLD HOOK RD
Practice Address - Street 2:
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1381
Practice Address - Country:US
Practice Address - Phone:646-335-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05549100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health