Provider Demographics
NPI:1770369647
Name:JERSEY SHORE MENTAL WELLNESS LLC.
Entity type:Organization
Organization Name:JERSEY SHORE MENTAL WELLNESS LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:IANNACONE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:609-713-5540
Mailing Address - Street 1:2640 HIGHWAY 70 STE 10
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-2612
Mailing Address - Country:US
Mailing Address - Phone:732-612-3188
Mailing Address - Fax:
Practice Address - Street 1:2640 HIGHWAY 70 STE 10
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-2612
Practice Address - Country:US
Practice Address - Phone:732-612-3188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty