Provider Demographics
NPI:1992094890
Name:TILLSON, JACQUELINE ANN (LPC, LCADC, NCC)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ANN
Last Name:TILLSON
Suffix:
Gender:F
Credentials:LPC, LCADC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DORSET DR
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-5010
Mailing Address - Country:US
Mailing Address - Phone:862-258-3231
Mailing Address - Fax:
Practice Address - Street 1:1 OLD WOLFE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BUDD LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07828-3213
Practice Address - Country:US
Practice Address - Phone:862-432-9783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00106500101YA0400X
NJ37PC00375000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional