Provider Demographics
NPI:1124242474
Name:LISTER, JENNIFER LORAINE (MSED, ATC, L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LORAINE
Last Name:LISTER
Suffix:
Gender:F
Credentials:MSED, ATC, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 VISTA LN
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1741
Mailing Address - Country:US
Mailing Address - Phone:412-512-2046
Mailing Address - Fax:646-797-8239
Practice Address - Street 1:523 E 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4099
Practice Address - Country:US
Practice Address - Phone:646-797-8232
Practice Address - Fax:646-797-8239
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT00135000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist