Provider Demographics
NPI:1730232950
Name:MULLANEY, JACQUELINE S (LSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:MULLANEY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 FROG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4319
Mailing Address - Country:US
Mailing Address - Phone:732-500-3511
Mailing Address - Fax:
Practice Address - Street 1:PREFERRED BEHAVIORAL HEALTH WRAP AROUND PROGRAM
Practice Address - Street 2:999 AIRPORT ROAD
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-367-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL054209001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018872Medicaid
NJ526788Medicare ID - Type UnspecifiedPBH AGENCY #