Provider Demographics
NPI:1114088853
Name:HECK-KANELLIDIS, JENNIFER A (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:HECK-KANELLIDIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 STATE ROUTE 35
Mailing Address - Street 2:SUITE 102 PLAZA 2
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3537
Mailing Address - Country:US
Mailing Address - Phone:732-663-1123
Mailing Address - Fax:732-663-1179
Practice Address - Street 1:1300 STATE ROUTE 35
Practice Address - Street 2:SUITE 102 PLAZA 2
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-3537
Practice Address - Country:US
Practice Address - Phone:732-663-1123
Practice Address - Fax:732-663-1179
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26N011956000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner