Provider Demographics
NPI:1831745082
Name:LANCE, JAQUANTE M (OTR)
Entity type:Individual
Prefix:
First Name:JAQUANTE
Middle Name:M
Last Name:LANCE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 EMPIRE BLVD APT 2S
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-5364
Mailing Address - Country:US
Mailing Address - Phone:910-489-4473
Mailing Address - Fax:
Practice Address - Street 1:3391 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2025
Practice Address - Country:US
Practice Address - Phone:910-489-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist