Provider Demographics
NPI:1194024505
Name:KENDORSKI, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KENDORSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 CRAWFORD PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3932
Mailing Address - Country:US
Mailing Address - Phone:856-448-5130
Mailing Address - Fax:
Practice Address - Street 1:41 PACELLA PARK DR
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-1755
Practice Address - Country:US
Practice Address - Phone:781-440-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
1-10-7326103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265Medicaid