Provider Demographics
NPI:1265039622
Name:FITTIPALDI, JESSICA VERONICA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:VERONICA
Last Name:FITTIPALDI
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1658
Mailing Address - Country:US
Mailing Address - Phone:732-447-8851
Mailing Address - Fax:
Practice Address - Street 1:170 PAULISON AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4810
Practice Address - Country:US
Practice Address - Phone:862-377-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002161002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer