Provider Demographics
NPI:1730836313
Name:IVAN, JESSICA LILA (RRT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LILA
Last Name:IVAN
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 WEISS TER
Mailing Address - Street 2:
Mailing Address - City:RARITAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08869-1631
Mailing Address - Country:US
Mailing Address - Phone:908-397-8242
Mailing Address - Fax:
Practice Address - Street 1:300 MADISON AVE FL 3
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-1868
Practice Address - Country:US
Practice Address - Phone:973-822-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ43ZA005129002279P1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2279P1006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Function TechnologistGroup - Single Specialty