Provider Demographics
NPI:1598073322
Name:LANDA, JESSICA (BS OT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:LANDA
Suffix:
Gender:F
Credentials:BS OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HALLBERG AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2615
Mailing Address - Country:US
Mailing Address - Phone:917-847-6678
Mailing Address - Fax:
Practice Address - Street 1:55 HALLBERG AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-2615
Practice Address - Country:US
Practice Address - Phone:917-847-6678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008112-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist