1043442593 NPI number — JOAN M. JERRIDO DPM

Table of content: JOAN M. JERRIDO DPM (NPI 1043442593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043442593 NPI number — JOAN M. JERRIDO DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERRIDO
Provider First Name:
JOAN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARVER
Provider Other First Name:
JOAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043442593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FEDERAL ST
Provider Second Line Business Mailing Address:
STE SW200
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-356-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 PLAZA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08080-9207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-270-4030
Provider Business Practice Location Address Fax Number:
856-270-4044
Provider Enumeration Date:
08/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  25MD00300100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 25MD00300100 . This is a "LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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