Basic Information
Provider Information | |||||||||
NPI: | 1891211959 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GIANGRANDE | ||||||||
FirstName: | JACLYN | ||||||||
MiddleName: | DANIELLE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 330 JORALEMON ST | ||||||||
Address2: |   | ||||||||
City: | BELLEVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 071092167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735171010 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 160 FRANKLIN AVE | ||||||||
Address2: |   | ||||||||
City: | NUTLEY | ||||||||
State: | NJ | ||||||||
PostalCode: | 071103075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9736670429 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2017 | ||||||||
LastUpdateDate: | 08/20/2017 | ||||||||
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 | 40QA01749600 | NJ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.