Healthcare Provider Details

I. General information

NPI: 1720689375
Provider Name (Legal Business Name): JENNIFER ROACH ZYLSTRA LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 SUMMERFIELD AVE
ASBURY PARK NJ
07712-6921
US

IV. Provider business mailing address

PO BOX 123
ROOSEVELT NJ
08555-0123
US

V. Phone/Fax

Practice location:
  • Phone: 732-774-6886
  • Fax: 732-774-8809
Mailing address:
  • Phone: 609-994-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06597400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: