Provider Demographics
NPI:1609235498
Name:DURHAM, JACQUELINE (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2026
Mailing Address - Country:US
Mailing Address - Phone:732-690-2611
Mailing Address - Fax:
Practice Address - Street 1:214 BROAD ST STE 2
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2027
Practice Address - Country:US
Practice Address - Phone:732-690-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055372001041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4144007Medicare UPIN
NJ31-4011Medicare PIN