Provider Demographics
NPI:1508658998
Name:JAQUEZ, EDISON A
Entity type:Individual
Prefix:
First Name:EDISON
Middle Name:A
Last Name:JAQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BURGESS LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-1638
Mailing Address - Country:US
Mailing Address - Phone:732-362-1897
Mailing Address - Fax:
Practice Address - Street 1:4228 S BROAD ST HAMILTON TOWNSHIP NEW JERSEY
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08620-2105
Practice Address - Country:US
Practice Address - Phone:609-475-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00871300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health