Healthcare Provider Details

I. General information

NPI: 1013586171
Provider Name (Legal Business Name): JENNIFER DEMOSTHENE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 LYONS AVE
NEWARK NJ
07112-2016
US

IV. Provider business mailing address

166 LYONS AVE
NEWARK NJ
07112-2016
US

V. Phone/Fax

Practice location:
  • Phone: 973-926-8491
  • Fax:
Mailing address:
  • Phone: 973-926-8491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ01359200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR20660900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: