Basic Information
| Provider Information | |||||||||
| NPI: | 1689639718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARRON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RAE-ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 CEDAR KNOLLS RD | ||||||||
| Address2: | |||||||||
| City: | CEDAR KNOLLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079271621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739988100 | ||||||||
| FaxNumber: | 9739988099 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 CEDAR KNOLLS RD | ||||||||
| Address2: | |||||||||
| City: | CEDAR KNOLLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079271621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739988100 | ||||||||
| FaxNumber: | 9739988099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2755 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | PT2755 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | PT2755 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 40QA01571000 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 154984721 | 05 | AR | MEDICAID |