Provider Demographics
NPI:1760146203
Name:PESCATORE, JESSICA (LAC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:PESCATORE
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 1:305 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1093
Mailing Address - Country:US
Mailing Address - Phone:609-365-0712
Mailing Address - Fax:609-904-2265
Practice Address - Street 1:305 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1093
Practice Address - Country:US
Practice Address - Phone:609-365-0712
Practice Address - Fax:609-904-2265
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00513100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0506290Medicaid