Provider Demographics
NPI:1528721651
Name:MENTOR, JERI FATIA
Entity type:Individual
Prefix:MS
First Name:JERI
Middle Name:FATIA
Last Name:MENTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7984
Mailing Address - Country:US
Mailing Address - Phone:732-908-6352
Mailing Address - Fax:
Practice Address - Street 1:132 PERRY ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-3968
Practice Address - Country:US
Practice Address - Phone:609-394-8988
Practice Address - Fax:609-394-0023
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3PC00867400101YP2500X
101YP2500X
NJ37LC00328700103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional