Provider Demographics
NPI:1912606476
Name:THOMASSON, JACQUELYN (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:THOMASSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 NJ-18
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857
Mailing Address - Country:US
Mailing Address - Phone:856-542-8547
Mailing Address - Fax:
Practice Address - Street 1:1405 NJ-18
Practice Address - Street 2:SUITE 106
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857
Practice Address - Country:US
Practice Address - Phone:856-542-8547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00672500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health