Provider Demographics
NPI:1881824761
Name:JARVIS, LYNNETTE (OTA)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:
Last Name:JARVIS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WINSTON DR APT 718
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-3214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 WINSTON DR APT 718
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PK
Practice Address - State:NJ
Practice Address - Zip Code:07010-3214
Practice Address - Country:US
Practice Address - Phone:201-888-0573
Practice Address - Fax:718-233-9688
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004683172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ320028878OtherNBCOT