Provider Demographics
NPI:1548916638
Name:LUCAS, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:LUCAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3243
Mailing Address - Country:US
Mailing Address - Phone:623-296-2034
Mailing Address - Fax:
Practice Address - Street 1:401 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3243
Practice Address - Country:US
Practice Address - Phone:623-296-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-27
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)