Provider Demographics
NPI:1679828156
Name:VANNEST, JESSICA (OTRL)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VANNEST
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 OAK ST
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4219
Mailing Address - Country:US
Mailing Address - Phone:732-581-6758
Mailing Address - Fax:732-358-0284
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:BUILDING 2
Practice Address - City:LANOKA HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08734-2228
Practice Address - Country:US
Practice Address - Phone:732-581-6758
Practice Address - Fax:732-358-0284
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00290300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist