Healthcare Provider Details

I. General information

NPI: 1508129172
Provider Name (Legal Business Name): JENNIFER MOJICA-ITIDIARE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MOJICA D.O.

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR SUITE 163
STRATFORD NJ
08084-1500
US

IV. Provider business mailing address

151 FRIES MILL RD STE 301
TURNERSVILLE NJ
08012-2016
US

V. Phone/Fax

Practice location:
  • Phone: 856-677-6708
  • Fax: 856-566-6222
Mailing address:
  • Phone: 856-513-4124
  • Fax: 856-302-5932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB09620200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: