Basic Information
Provider Information | |||||||||
NPI: | 1558690412 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JORDAN | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FILLER | ||||||||
OtherFirstName: | JENNY | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 66 W GILBERT ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | TINTON FALLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 077014947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322120051 | ||||||||
FaxNumber: | 7322120713 | ||||||||
Practice Location | |||||||||
Address1: | 325 MAPLE AVE | ||||||||
Address2: |   | ||||||||
City: | RED BANK | ||||||||
State: | NJ | ||||||||
PostalCode: | 077012104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7327411119 | ||||||||
FaxNumber: | 7322120713 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/23/2009 | ||||||||
LastUpdateDate: | 04/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01287600 | NJ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.