Provider Demographics
NPI:1386922052
Name:HERZOG, JILLELLEN (LPC)
Entity type:Individual
Prefix:
First Name:JILLELLEN
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 OVERTON PL
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-5408
Mailing Address - Country:US
Mailing Address - Phone:732-263-9349
Mailing Address - Fax:
Practice Address - Street 1:55 N GILBERT ST
Practice Address - Street 2:SUITE 3202
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4955
Practice Address - Country:US
Practice Address - Phone:732-500-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00425200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional