Provider Demographics
NPI:1275910846
Name:TYRRELL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TYRRELL
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 1:110 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-2817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 W 32ND ST STE 604
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3884
Practice Address - Country:US
Practice Address - Phone:201-282-9553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-02
Last Update Date:2015-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019580-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics