1114594249 NPI number — JACLYN SUZANNE NORTHRIDGE LCSW

Table of content: JACLYN SUZANNE NORTHRIDGE LCSW (NPI 1114594249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114594249 NPI number — JACLYN SUZANNE NORTHRIDGE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORTHRIDGE
Provider First Name:
JACLYN
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERRIOS
Provider Other First Name:
JACLYN
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114594249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 UNIVERSITY DR MC CA410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERSHEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17033-2360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-531-1159
Provider Business Mailing Address Fax Number:
717-531-0119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 NORTHEAST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERSHEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17033-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-531-8338
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW024163 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)