Provider Demographics
NPI:1669509444
Name:JENGO, LUCILLE M (MSW)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:M
Last Name:JENGO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 US HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-1015
Mailing Address - Country:US
Mailing Address - Phone:973-263-8070
Mailing Address - Fax:973-263-8666
Practice Address - Street 1:3599 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-1015
Practice Address - Country:US
Practice Address - Phone:973-263-8070
Practice Address - Fax:973-263-8666
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000063001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ634494Medicare ID - Type Unspecified