Provider Demographics
NPI:1851574552
Name:LARGE, JESSICA M (MA, EDS LPC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:LARGE
Suffix:
Gender:F
Credentials:MA, EDS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 WOODPORT RD STE 209
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-2645
Mailing Address - Country:US
Mailing Address - Phone:973-512-3700
Mailing Address - Fax:973-512-3700
Practice Address - Street 1:191 WOODPORT RD STE 209
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-2645
Practice Address - Country:US
Practice Address - Phone:973-512-3700
Practice Address - Fax:973-512-3700
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00410400101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health