Provider Demographics
NPI:1225095607
Name:JANNICELLI, JASON R (MS PAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:JANNICELLI
Suffix:
Gender:M
Credentials:MS PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 ARDEN RD
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-1888
Mailing Address - Country:US
Mailing Address - Phone:908-377-9488
Mailing Address - Fax:
Practice Address - Street 1:110 REHILL AVE # 08876
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2519
Practice Address - Country:US
Practice Address - Phone:908-685-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00151700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant