Provider Demographics
NPI:1215293576
Name:VICTORIA-PROANO, JENNIFER J (MA, LAC, CBIS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:VICTORIA-PROANO
Suffix:
Gender:F
Credentials:MA, LAC, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18-01 POLLITT DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2815
Mailing Address - Country:US
Mailing Address - Phone:201-478-4200
Mailing Address - Fax:201-478-4202
Practice Address - Street 1:18-01 POLLITT DRIVE SUITE 1A
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-478-4200
Practice Address - Fax:201-478-4202
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00060900101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor