Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 46TR00383000 | NJ |
NPI | 1053960963 |
---|---|
Provider Name | Jessica Lynch |
First Address | Wyckoff, NJ 07481-3213 |
Second Address | Wyckoff, NJ 07481-3213 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2019 |
Last Update Date | 04/09/2019 |