Provider Demographics
NPI:1699093138
Name:FUDALA, JESSICA (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FUDALA
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 1:438 WINDING WAY
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-4940
Mailing Address - Country:US
Mailing Address - Phone:732-477-5035
Mailing Address - Fax:
Practice Address - Street 1:999 AIRPORT ROAD WRAP AROUND
Practice Address - Street 2:PREFERRED CHILDRENS SERVICES
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-367-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054132001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018872Medicaid