Healthcare Provider Details

I. General information

NPI: 1275707804
Provider Name (Legal Business Name): ANTHONY G. JONGEJAN MMP, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

664 SCRANTON RD STE 101
BRUNSWICK GA
31520-1945
US

IV. Provider business mailing address

211 WELLINGTON PL
BRUNSWICK GA
31523-7067
US

V. Phone/Fax

Practice location:
  • Phone: 912-577-3991
  • Fax:
Mailing address:
  • Phone: 912-577-3991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT002240
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: