Provider Demographics
NPI:1609582766
Name:LASSOR, JESSA (APN)
Entity Type:Individual
Prefix:
First Name:JESSA
Middle Name:
Last Name:LASSOR
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLYN
Mailing Address - State:NJ
Mailing Address - Zip Code:08107-1321
Mailing Address - Country:US
Mailing Address - Phone:609-364-8735
Mailing Address - Fax:
Practice Address - Street 1:875 MANTUA PIKE STE B
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3337
Practice Address - Country:US
Practice Address - Phone:856-384-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01422500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily