Provider Demographics
NPI:1861149205
Name:MASTRODOMENICO, JORDYN L (LAC LCADC)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:L
Last Name:MASTRODOMENICO
Suffix:
Gender:F
Credentials:LAC LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SPEAR RD STE 303
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-1223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 SPEAR RD STE 303
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1223
Practice Address - Country:US
Practice Address - Phone:551-427-6540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00488900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty