Provider Demographics
NPI:1114749215
Name:TABAKIN, JESSAMYN BLAKESLEE (LCSW)
Entity type:Individual
Prefix:
First Name:JESSAMYN
Middle Name:BLAKESLEE
Last Name:TABAKIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SETON PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2514
Mailing Address - Country:US
Mailing Address - Phone:917-612-8992
Mailing Address - Fax:
Practice Address - Street 1:124 SETON PL
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2514
Practice Address - Country:US
Practice Address - Phone:091-761-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC061499001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical