Provider Demographics
NPI:1720228166
Name:WALLACH, JENNIFER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:WALLACH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 CEDAR LN FL 1
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1702
Mailing Address - Country:US
Mailing Address - Phone:646-239-8032
Mailing Address - Fax:
Practice Address - Street 1:705 CEDAR LN FL 1
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-1702
Practice Address - Country:US
Practice Address - Phone:646-239-8032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018153103TC0700X, 103TC2200X
NJ4796103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical