Provider Demographics
NPI:1790060523
Name:HERRERA JARA, FANY
Entity Type:Individual
Prefix:
First Name:FANY
Middle Name:
Last Name:HERRERA JARA
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 1:301 LAFAYETTE AVE
Mailing Address - Street 2:APT 3C
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2559
Mailing Address - Country:US
Mailing Address - Phone:917-349-6132
Mailing Address - Fax:
Practice Address - Street 1:301 LAFAYETTE AVE
Practice Address - Street 2:APT 3C
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-2559
Practice Address - Country:US
Practice Address - Phone:917-349-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019565-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist