Basic Information
| Provider Information | |||||||||
| NPI: | 1194024505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENDORSKI | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLASS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 CRAWFORD PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080543932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564485130 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41 PACELLA PARK DR | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023681755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814400400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | 1-10-7326 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 110026265 | 05 | MA | MEDICAID |