Provider Demographics
NPI:1114594249
Name:NORTHRIDGE, JACLYN SUZANNE (LCSW)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:SUZANNE
Last Name:NORTHRIDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:SUZANNE
Other - Last Name:BERRIOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:500 UNIVERSITY DR MC CA410
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:717-531-1159
Mailing Address - Fax:717-531-0119
Practice Address - Street 1:22 NORTHEAST DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2732
Practice Address - Country:US
Practice Address - Phone:717-531-8338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0241631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical