Provider Demographics
NPI:1215263470
Name:MERRIAM, JENNIFER (MSOT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MERRIAM
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3001
Mailing Address - Country:US
Mailing Address - Phone:973-972-0186
Mailing Address - Fax:973-972-2645
Practice Address - Street 1:65 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3001
Practice Address - Country:US
Practice Address - Phone:973-972-0186
Practice Address - Fax:973-972-2645
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00461200225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics