Provider Demographics
NPI:1760285027
Name:DISTEFANO, JESSICA (MS, LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 LAREINE AVE UNIT 318
Mailing Address - Street 2:
Mailing Address - City:BRADLEY BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:07720-1065
Mailing Address - Country:US
Mailing Address - Phone:732-674-3255
Mailing Address - Fax:
Practice Address - Street 1:800 W MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2555
Practice Address - Country:US
Practice Address - Phone:732-655-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00782300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty