Provider Demographics
NPI:1508129172
Name:MOJICA-ITIDIARE, JENNIFER (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MOJICA-ITIDIARE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MOJICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:151 FRIES MILL RD STE 301
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:856-513-4124
Mailing Address - Fax:856-302-5932
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 163
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1500
Practice Address - Country:US
Practice Address - Phone:856-677-6708
Practice Address - Fax:856-566-6222
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB09620200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0474550Medicaid