Provider Demographics
NPI:1700531779
Name:BENNETT, JACLYN M
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PICKEREL POINT DR
Mailing Address - Street 2:
Mailing Address - City:HOPATCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07843-1618
Mailing Address - Country:US
Mailing Address - Phone:862-219-8525
Mailing Address - Fax:
Practice Address - Street 1:16 POCONO RD STE 107
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2905
Practice Address - Country:US
Practice Address - Phone:862-219-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00841400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health