Healthcare Provider Details

I. General information

NPI: 1992154132
Provider Name (Legal Business Name): JENNIFER LYNN FARESTAD AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 FEDERAL ST
CAMDEN NJ
08103-1539
US

IV. Provider business mailing address

30 NORTH PEARL STREET
BRIDGETON NJ
08302
US

V. Phone/Fax

Practice location:
  • Phone: 856-583-2400
  • Fax:
Mailing address:
  • Phone: 609-790-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00621700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: