1538428263 NPI number — MRS. JESSICA PEARL SPENCER BOND MA, ATC

Table of content: VAJRESHWARI SHIVAPRAKASH MD (NPI 1396770806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538428263 NPI number — MRS. JESSICA PEARL SPENCER BOND MA, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER BOND
Provider First Name:
JESSICA
Provider Middle Name:
PEARL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538428263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 AMY LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABSECON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-602-6294
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 VERA KING FARRIS DR
Provider Second Line Business Practice Location Address:
OFFICE OF ATHLETICS AND RECREATION, ROOM 309
Provider Business Practice Location Address City Name:
GALLOWAY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08205-9441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-652-4544
Provider Business Practice Location Address Fax Number:
609-652-4709
Provider Enumeration Date:
05/15/2012

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: 2255A2300X , with the licence number:  25MT00117800 , 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)





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