Provider Demographics
NPI:1255062188
Name:DELVESCIO, JENNA MARIE (DPT)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:DELVESCIO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 FOREST ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3906
Mailing Address - Country:US
Mailing Address - Phone:609-742-0104
Mailing Address - Fax:
Practice Address - Street 1:1199 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1424
Practice Address - Country:US
Practice Address - Phone:197-341-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02096500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA02096500OtherPHYSICAL THERAPIST