Provider Demographics
NPI:1386430965
Name:BENVENUTO, JORDAN (COTA/L)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BENVENUTO
Suffix:
Gender:
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:STANHOPE
Mailing Address - State:NJ
Mailing Address - Zip Code:07874-3411
Mailing Address - Country:US
Mailing Address - Phone:862-432-1262
Mailing Address - Fax:
Practice Address - Street 1:299 CHERRY HILL RD STE 108
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-1124
Practice Address - Country:US
Practice Address - Phone:833-587-1784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09190100224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant