Provider Demographics
NPI:1104324490
Name:JACK, SARAH L (LCSW, LMSW)
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:L
Last Name:JACK
Suffix:
Gender:F
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3311
Mailing Address - Country:US
Mailing Address - Phone:917-568-8640
Mailing Address - Fax:
Practice Address - Street 1:1060 MAIN ST STE 303
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2592
Practice Address - Country:US
Practice Address - Phone:201-488-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY052883-11041C0700X
NJ44SC058831001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical