Basic Information
| Provider Information | |||||||||
| NPI: | 1093880668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANK | ||||||||
| FirstName: | JARED | ||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2619 CULVER RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853422410 | ||||||||
| FaxNumber: | 5853429141 | ||||||||
| Practice Location | |||||||||
| Address1: | 2619 CULVER RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853422410 | ||||||||
| FaxNumber: | 5853429141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 021951-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 021951-1 | 01 | NY | PT LICENSE | OTHER |