Provider Demographics
NPI:1205257805
Name:AVANZADO, JOBECCA
Entity type:Individual
Prefix:
First Name:JOBECCA
Middle Name:
Last Name:AVANZADO
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 1:127 OLD SHORT HILLS RD APT 213
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1014
Practice Address - Country:US
Practice Address - Phone:908-522-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
MARN2290398163W00000X
NY532278163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
10001000OtherPRIVATE