Provider Demographics
NPI:1679063242
Name:NORTH JERSEY COMMUNITY RESEARCH INITIATIVE
Entity Type:Organization
Organization Name:NORTH JERSEY COMMUNITY RESEARCH INITIATIVE
Other - Org Name:NJCRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-483-3444
Mailing Address - Street 1:393 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2842
Mailing Address - Country:US
Mailing Address - Phone:973-483-3444
Mailing Address - Fax:
Practice Address - Street 1:393 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2842
Practice Address - Country:US
Practice Address - Phone:973-483-3444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000633261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0538027Medicaid