Provider Demographics
NPI:1811549215
Name:PIDICH, JACQUELINE MARIE (LPC, ATR- BC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:PIDICH
Suffix:
Gender:F
Credentials:LPC, ATR- BC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:PIDICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1132 EASTON AVE APT C
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1628
Mailing Address - Country:US
Mailing Address - Phone:908-644-4397
Mailing Address - Fax:
Practice Address - Street 1:1132 EASTON AVE APT C
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-1628
Practice Address - Country:US
Practice Address - Phone:908-644-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ15-333221700000X
NJ37PC00618000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist