Provider Demographics
NPI:1235658105
Name:D'ERMILIO, JODIE
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:D'ERMILIO
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 1:278 BROAD ST UPPR
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3229
Mailing Address - Country:US
Mailing Address - Phone:732-887-4323
Mailing Address - Fax:
Practice Address - Street 1:278 BROAD ST UPPR
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-3229
Practice Address - Country:US
Practice Address - Phone:732-887-4323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00835700225X00000X
FLOT18471225X00000X
IL056011988225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist