Provider Demographics
NPI:1790282788
Name:JEDLICKA, CARA JEAN (LAC)
Entity Type:Individual
Prefix:MRS
First Name:CARA JEAN
Middle Name:
Last Name:JEDLICKA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:PROF
Other - First Name:CARA JEAN
Other - Middle Name:
Other - Last Name:JEDLICKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:10 OLYMPIA DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3844
Mailing Address - Country:US
Mailing Address - Phone:856-905-3136
Mailing Address - Fax:
Practice Address - Street 1:100 WHITE HORSE RD E
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2504
Practice Address - Country:US
Practice Address - Phone:856-866-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00403500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional