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General NPI Number Information
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NPI Number | 1124242474
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Entity Type | Individual
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Provider Name | JENNIFER LORAINE LISTER MSED, ATC, L
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Gender | Female
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 04/19/2021
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Provider Practice Location Address
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Address Line | 523 E 72ND ST
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City | NEW YORK
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State | NY
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Zip | 10021-4099
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Country | US
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Telephone | 646-797-8232
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Fax | 646-797-8239
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Provider Business Mailing Address
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Address Line | 14 VISTA LN
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City | NEW PROVIDENCE
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State | NJ
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Zip | 07974-1741
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Country | US
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Telephone | 412-512-2046
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Fax | 646-797-8239
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25MT00135000
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License Number State | NJ
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