Basic Information
| Provider Information | |||||||||
| NPI: | 1700139540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEROULD | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 GALWAY PL | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076663640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018339500 | ||||||||
| FaxNumber: | 2018620095 | ||||||||
| Practice Location | |||||||||
| Address1: | 663 PALISADE AVE | ||||||||
| Address2: | |||||||||
| City: | CLIFFSIDE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070103012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019439100 | ||||||||
| FaxNumber: | 2019437308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 25MP00293700 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.