Provider Demographics
NPI:1962904326
Name:ETHIRVEERASINGAM, JENNIFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:ETHIRVEERASINGAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 CENTER AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2260
Mailing Address - Country:US
Mailing Address - Phone:201-755-2367
Mailing Address - Fax:
Practice Address - Street 1:54 CENTER AVE FL 1
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07424-2260
Practice Address - Country:US
Practice Address - Phone:201-755-2367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009614-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty