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General NPI Number Information
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NPI Number | 1912844309
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Entity Type | Individual
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Provider Name | MRS. SAMANTHA RAVEN JACONETTI
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Gender | Female
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Dates
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Enumeration Date | 05/02/2026
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Last Update Date | 05/02/2026
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Provider Practice Location Address
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Address Line | 769 ROUTE 70 E STE C175
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City | MARLTON
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State | NJ
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Zip | 08053-2360
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Country | US
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Telephone | 609-276-8553
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Fax |
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Provider Business Mailing Address
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Address Line | 50 JACKSON RD
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City | BERLIN
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State | NJ
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Zip | 08009-1611
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Country | US
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Telephone | 856-287-5705
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Fax |
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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 | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 46TA09266200
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License Number State | NJ
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